The phenomena of ageing populations is well known as a UK and an international challenge. The increases in the proportions of the population which is deemed elderly (65+) and very elderly (80+) are forecast to continue and it is said that one in four children born today will live to be 100.
The aging population has implications in a number of areas such as: health, housing, labour supply to the economy, pensions etc but one of the biggest challenges concerns social care for the elderly. The provision of social care to the elderly can range from giving a small amount of support to elderly persons living independently in their own home to the provision of 24 hour residential care and nursing care. As the numbers of elderly and very elderly increase so does the volume of social care needed increase.
While this has been a looming issue for many years, what has exacerbated the situation is the application of financial austerity measures to public services and, in particular, to local authorities who have primary responsibility for the delivery of social care to elderly persons. In the last few weeks, media reports have commented on some local authorities being close to collapse because of the funding pressures of the ageing population.
What is certain is that we cannot go on as we are. The well-known Barnet Graph of Doom shown below indicates that if nothing changes then by 2022/23 the costs of adult social care and children’s services will exceed the council’s total budget with nothing left for all the other services. Clearly this cannot happen but it does indicate the grave problem facing local government
The simple aim must be to reduce the proportion of the elderly going into residential (or nursing care) and increase the proportion receiving other forms of social care such as homecare, sheltered housing etc. This is not just about the costs involved but the feasibility of delivering increasing volumes of residential care when considering
· The current instability in the residential care market which does not seem likely to disappear in the near future. Indeed last week it was reported that several private providers were planning to withdraw from the residential care market because of a lack of profitability on current tariffs
· The possible problems with the supply of social care labour particularly as a consequence of BREXIT. A large proportion of social care is already provided by Eastern Europeans who may not remain in the UK
So what is to be done? Well in the short term, the only option appears to be for the government to provide additional funding to keep the ship afloat until a wide range of measures can be implemented to provide a greater degree of stability. To achieve this stability, in the longer term, there must be substantial changes in the way adult social care for the elderly is organised, funded and provided and in the interface between health and social care. This is especially true since austerity is set to continue for the foreseeable future.
Significant change is required in many areas and unfortunately, there are no easy options since all of the “low hanging fruit” has already been picked in the early years of austerity. What is being talked about here is a complex and potentially expensive exercise which needs to be examined and evaluated carefully – one size will not fit all. The change process involved will, undoubtedly be difficult but it cannot be relegated to the “too difficult” box. This fact must be widely communicated, among staff, services users and politicians in that if we don’t address these issues we face disaster – do nothing is not an option
Based on work I have done recently, I suggest the changes required are wide ranging and will cover the following:
Firstly, social housing. In shire counties adult social care for the elderly is an upper tier responsibility while housing is a responsibility of the lower tier. The planning for the housing needs of the elderly is not always done well and often the districts within the county have different views. Improved co-ordination of public housing policies for the elderly must be undertaken. This should not be read as meaning that planning the housing needs of the elderly is always done well in unitary authorities.
With regard to private housing, it must be recognized that many elderly people have the financial resources to purchase a property suitable for their needs. Hence, there is a need for the local authorities to work more proactively with the private housing providers regarding housing for the elderly
Many elderly patients suffer a crisis and end up being admitted into an acute hospital and from there go straight to residential care – probably after blocking acute beds for several weeks. The key is to reduce the impact of these sorts of situations with the aim of keeping elderly people in their own homes
There is evidence that this can be mitigated by major reforms of health and social care services at the local level. This would involve a combination of
· The strengthening of primary care and an enhancement of the role of GPs
· The reconfiguration and strengthening of intermediate care of the elderly through the development of community based clinicians acting as a single point of access to a range of services, as a means dealing with the crisis and returning people to their homes.
However, these changes do not require major policy announcements from central government or the creation of special funds which are administratively difficult to access and too small to make a difference. What is needed is leadership and vision at the local level and the development of good partnerships between the various bits of the NHS and local government.
However, the process could be assisted by changes to the funding mechanisms of health and local government which often work against such collaboration and not for it. Currently, commissioners end up paying NHS Trusts to keep elderly patients in acute beds because there is a lack of funding or capacity to move them into social care which would free up the acute beds. Surely, it is not beyond the wit of man to devise funding mechanisms to overcome these difficulties.
Changing service paradigm
To a large extent, the existing paradigm of social care comprises a number of features including the view that elderly people need ongoing support and that the professionals know best. There is a need to shift social care services for the elderly to a new service paradigm more appropriate to the challenges of the future and to reshape existing services in line with this paradigm. In particular, while some people will need ongoing support, other elderly persons need to be empowered and given confidence to maximise the extent to which they can look after themselves, at home, with minimum support. This requires a major change in the skills base and outlook of many service professionals and will need to be reflected in professional training regimes
The use of technology
In the private sector, information technology has revolutionized the way in which companies do business. Just think about the growth in online shopping and the decline in store shopping.
While social care for the elderly will always require some degree of personal human contact there is considerable scope for using technology in a variety of ways to support social care of the elderly (see http://www.kingsfund.org.uk/publications/articles/eight-technologies-will-change-health-and-care. Hence there is a need to be pro-active about the identifying the potential for using this technology in delivering services to the elderly (taking account the points made above about changing the services themselves) and for having a robust operational and financial plan to put this into effect. Piecemeal approaches will probably fail to have major impacts.
Utilising spare capacity
There is a need to utilise whatever spare capacity can be found to support social care for the elderly at little cost. This could involve a number of approaches including:
· Using other public service professionals (such as firefighters) who have spare capacity because of the emergency nature of much of their work and who could provide some support to elderly persons. Some fire authorities have already made great strides in this area but there may be other possibilities to be explored with regard to ambulance and police services
· In developing countries, in Asia and Africa, social care for the elderly is rudimentary on non-existent but the population is ageing in a similar manner to that of developed countries. For financial reasons, one of the few options available to these countries is to stimulate voluntary support capacity in cooperation with third sector agencies. Similar approaches might be enhanced in the UK but would need some funding support in order to regulate and train the voluntary support workers
The key thing to realise is that what is described above must be seen as a holistic package and a journey not a pick and choose exercise. Thus it must be recognised that all of what is described above (and more) has three major implications:
· A need for political buy-in
· A need for significant financial investment up front to reduce downstream costs in the years ahead
· Recognition that these changes involve a significant management of change effort which has both financial and managerial implications
In turn, this requires a strong focus on a number of key things
· Robust project evaluation to identify which approaches are likely to succeed
· Effective project management to achieve successful implementation
· Good financial planning and forecasting to ensure that there are not cost overruns
· The need to find funds from existing resources in order to reinvest in new services. I really believe that this is something that public authorities need to do themselves rather than rely on hand outs from central government which are often administratively complex and have too many strings attached to make it worthwhile.
· The need to ensure savings from the rationalisation of existing services are actually realised. To fail to do this destroys the rationale for the change
· A recognition of the need for major management of change programmes
ConclusionWhile not everyone will agree with everything I have had to say on this matter, I think everyone will agree that it is imperative that action is needed. Popular culture has it that the Emperor Nero fiddled while Rome burned down. I want to argue that it is incumbent on local authorities and NHS organisations to rise to the challenges themselves and not wait for central government to play their fiddle.