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24th February 2017

Welsh thoughts from Manchester

There’s nothing quite like travelling (across Offa’s Dyke) to sharpen the mind’s focus on domestic (Welsh) issues.

I’m writing this from Manchester, where I’m the guest of a university department for an afternoon. Always one for learning, I’ve been taking note of the conversation taking place about continued funding for health and social care , and trying to draw lessons for Wales. In Manchester, as throughout the UK, there is pressure from two main directions. Firstly, austerity is tightening the budget strings, whilst at the same time - demand is rising with demographic changes and longevity.

New thinking is required to balance the books and develop service models which can meet demand. In Tameside and Glossop, 250 000 people are anticipating a radical transformation of health and social care services – becoming the first borough in Greater Manchester to open a Local Care Organisation. This project will merge hospital, communities, voluntary organisations and social care working into a single service. Brave new thinking indeed!

Where now for Wales?

So where are we at in Wales? Austerity continues, money is tight and services are under pressure. As long ago as April 2013 the First Minister, Carwyn Jones stated prophetically;

"Since public sector budgets are likely to continue to tighten, and demand pressures grow, there is a clear need to examine how services can be sustained and standards of performance raised, so that people in Wales can continue to receive and influence the public services they need and value.” BBC News, April 2013.

Compared to the UK as a whole, Wales has more older people and lower income levels.  The move towards reform must take account of this. The Welsh Government has actively been considering how social care services can be placed upon a sustainable and fairer footing. Some of its actions include:

  • A review of local government in Wales culminating in a 2015 Act.
  • A consultation paper on paying for care;
  • Creating a paying for care stakeholder advisory group; ¢
  • The introduction in April 2011 of a weekly maximum local authority charge for non-residential care and support.
  • Funding research into further options for reform.

I’ve briefly considered (in a personal capacity), and noted down some thoughts, from three perspectives;

  1. Eligibility for care;
  2. Organisational structures;
  3. Funding.

Eligibility

Finite resources require that those with the highest levels of need are prioritised. Historically decisions about eligibility for care have rested with a range of services to special-needs groups. Each service defined their own threshold for accessing services. However, this made managing access difficult. The Social Services and Wellbeing (Wales) Act, 2014 recognised the requirement to prioritise the most needy and vulnerable and enacted measures to reserve services for this group. Central to this intent is the single point of entry “can and can only” test, which provides the means by which to identify those who cannot reasonably have their needs met, other than by provision of a care and support package.

A manageable ‘entry-gate’ into the service, or a super-high ‘rationing’ threshold for accessing care and support?

Organisational Structures

Much work has been undertaken at Welsh Government to combine the health and social care budgets. This simple fact recognises that the two systems are interdependent but hasn’t in itself moved social care on to a sustainable footing.

The discrepancy between the number of health boards (7) and local authorities (22) makes joint planning and commissioning more difficult. Whilst reform of local government has been on the agenda for a number of years, it seems to have been parked since the 2016 Assembly elections, and must surely be part of the long-term solution. There does appear to be economies of scale which could be achieved by merging authorities to a proposed number of eight or nine. However, there may also be local resistance and costs involved in setting up the merged authorities in the short-term.

Successive reorganisations have been expensive, destabilised services and disenfranchised the public. It’s time to settle on structures which will be effective and durable.

Funding        

Funding for residential or domiciliary care in Wales is shared between the state (NHS/local authority) and the individual depending upon the exact circumstances. There appears to be consensus around the notion that the current formula is insufficient to sustain the sector and risks major-providers becoming unviable and failing. Whilst in England, local authorities have been invited to consider increasing their social care funding through an increased social care ‘precept’ within council tax, no such proposal has been made in Wales. The projected shortfall in funding needs bridging. Whist preventative public-health initiatives may pay off in the longer term, service planning needs to be based on the increased prevalence of conditions requiring support, such as learning disabilities and dementia. The main options appear to be either insurance based (private and/or state social care funds) or via increased taxation.

More money is needed, in Wales as elsewhere, it is time to have a mature discussion about which option fits best.

Surely there will need to be an increase in national/local tax and/or a social care insurance scheme to provide sustainable services in the future.

Read more about options for funding care in Wales at:

http://gov.wales/docs/dhss/publications/161014chargingresearchen.pdf

*All information is correct at the time of publishing

Nic Bowler

Welsh Care and Social Services Inspectorate Specialist

Dr Nicholas Bowler is a researcher and consultant to government-level [Welsh Government Review of Secure Services, 2009] – specialising in QA/compliance focused projects. He has interests in clinically relevant training, service development and research. He enjoys working with clients to support them in identifying problems and initiating projects to improve practice.

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