Bankrupt: a council in crisis and the impact on health and social careBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l172 (Published 05 February 2019) Cite this as: BMJ 2019;364:l172
As the NHS in England begins implementing its plan for spending its additional £20bn (€22.2bn; $25.5bn) over the next 10 years,1 a growing number of local authorities facing financial crisis are slashing adult social care budgets.
The long term impact on health services will be profound, affecting everything from hospital discharge to falls prevention and rehabilitation. According to the Association of Directors of Adult Social Services, councils in England are taking out £700m from their adult spending this financial year, 4.7% of that budget.2
East Sussex County Council is planning to strip its services back to a “core offer,”3 which includes reducing services for vulnerable children and adults. Worcestershire County Council is looking to shed around 200 staff—which will have a serious impact on child and adult social care which accounts for almost 70% of its budget.4 Other councils facing serious financial pressures include Cornwall, Lincolnshire, Somerset, Surrey, and Torbay.
Northamptonshire County Council—whose problems have been exacerbated by mismanagement5—is in the deepest trouble. Last autumn, it adopted a financial stabilisation plan: targets include saving £700 000 by reducing long term care placements from hospital and £1.8m from “new ways of delivering care and independence.”
Local health service leaders are concerned about the impact of the cuts on the wider health and care system; many important but non-statutory services are being badly hit, such as support for welfare rights advice and a home repair service for elderly and vulnerable people.
The county has, however, been running services that are both expensive and often inappropriate, so it should be possible to redirect money.
There has been misspending on people with learning disabilities, for example. Anna Earnshaw, adult social services managing director at Northamptonshire County Council, says: “Half of all our customers are under 65 and many of them are learning disabled.
“The stabilisation plan recognises that what we’re doing at the moment is costing us a lot of money, especially in residential care, because we don’t have enough supported living solutions.”
Poor commissioning of services means Northamptonshire is currently spending an average of around £70 000 a year to keep a person with learning disabilities in residential care, £20 000 more than the average of surrounding councils. Many of these service users would be better cared for in supported living accommodation at a cost of £25 000—a saving of £45 000 per person per year.
The council is also spending too much on people leaving hospital. “About 60% of our demand for services comes from the hospitals,” says Earnshaw. “The referrals we get are twice the regional average—the norm is about 30%.”
So the local NHS and council are investing in intermediate care to get people out of hospital more quickly and to stop them having to go into long term care.
Domiciliary care bills are being racked up by allocating excessive care packages to people leaving hospital, a problem exacerbated by some still being assessed for their needs while they are in the unfamiliar hospital surroundings rather than being “discharged to assess.”
“If we can do more to get the right level of care from the beginning then we release more capacity for homecare,” Earnshaw says. “The winter plans that we have put in place are all about not doing any assessment in hospital—either move them home or to an interim bed to assess.”
Shortages of care
Nurse Nicki Slawson is clinical lead for Seatons Solicitors, which represents many people caught by the funding shortages across health and social care in Northamptonshire. People in need of both mental and physical health support have had to “wait until they get into a crisis,” she says. “They are firefighting the whole time on the frontline. Staff are dealing with it crisis by crisis.”
Slawson sees the problems caused by a shortage of intermediate care: “People are often not given the opportunity to go into rehabilitation or go home, so they are ending up in care homes when probably they shouldn’t be.”
She cites cases of people who have had modest social services support and are then admitted to hospital. After treatment they are moved to a “discharge to assess” bed, intended to allow them to have their needs assessed in their own home. After waiting three or four weeks for social services—or sometimes the NHS—to carry out the assessment they have lost their ability to live independently “so they end up in permanent care. It really bugs me.”
One woman was kept in hospital for six months and then discharged to an assessment bed; but no one gave her back her Zimmer frame, Slawson says, so by the time she was assessed she had lost her mobility.
Age UK, which has around 14 000 clients in Northamptonshire, also highlights the lack of intermediate care as “one of the big problems that acute hospitals are wrestling with.”
“Intermediate care is a problem for all health systems, everywhere: getting the right support for people at the right time,” says the charity’s chief executive for the county, Christopher Duff.
“The real answer is to provide ongoing support for people in their homes,” Duff adds, yet difficulties in accessing domiciliary care are also having a significant impact. “We see it often. If domiciliary care isn’t there then patients are readmitted to hospital. There is another fall, or drugs regimes aren’t adhered to, or they sink further into loneliness and poor mental health, and they become even less independent.”
Joint assessment issues
Slawson believes that “more than dozens” of people have ended up selling their homes to pay for a care home place unnecessarily—either because they should have had a support package to keep them in their own home or because their primary condition is medical so they should have qualified for NHS support but were wrongly treated as having a social care requirement that then has to be funded.
“Although it would be brilliant if health and social care worked together it just doesn’t happen because both sides are trying to protect their budgets,” Slawson says.
She cites the case of a man who had severe cognitive impairment, no verbal communication, double incontinence, needed constant skin maintenance, and had to have his food and drugs administered through a tube in his stomach, “so a really high level of need, which should not be treated and funded as social care. That is healthcare.” The ruling is being appealed.
Earnshaw acknowledges problems around joint assessments of health and social care needs: “It is a national challenge. One of you gets the cost. We need joint assessments that reasonably split the costs. We are in a good place already with learning disability and mental health clients, and we probably need to do it more around older people.”
Mark Major, chief executive of Northamptonshire Carers—and chair of Northamptonshire Carers’ Partnership, which involves charities, the county councils, and NHS providers—says support for carers continues to be good. Cuts have had significant impact elsewhere, however, such as for deaf and visual impairment support and advice services, and it is taking longer to access care.
“The county council has got backlogs of unallocated cases and backlogs around safeguarding,” Major says. In February 2018, the council admitted its adult services were on the “edge of being unsafe,” with 2000 unassigned cases. The number has since fallen.
Next big risk
The next big complication facing social services in Northamptonshire is the decision to abolish the council and all its districts, and divide the county into two unitary authorities—providing all local government services—in 2020.
Earnshaw says: “We have to have safe landing from day one, so no one falls through the gaps. We may need to keep some teams—particularly safeguarding and quality—at a county level in the first instance so we don’t disrupt them.”
Her key advice for other councils facing a budget crisis is: “Don’t cut back too far on your capacity. If there are too few staff, it exacerbates problems by taking too long to put care in place and scale it back when it is no longer needed.
“If you don’t have the capacity to do that then every assessment becomes a crisis and patients are far more likely to end up in long term care or hospital.”