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  1. Do you have a regular mailshot to your members by email or post? if so I would be grateful if you could share the following article, please?

    Chris J Perry MA, CSW
    Former Director of Social Services, South Glamorgan County Council
    Former Non-Executive Director, Winchester and Eastleigh Healthcare NHS Trust
    Former Director of Age Concern Hampshire

    There is little point throwing more money at the NHS when the most cost effective way to resolve the funding crisis in health and social care is to increase pensions, coupled with radical reform based upon a whole systems review. The NHS and Social Care are in crisis, 1.9m older people are living in poverty and more and more older people are having to sell their houses to pay for their care in this the fifth largest economy in the world.

    However it cannot be solved at a “component level” by pouring more and more resources into the first aid camp at the bottom of the cliff, rather than building a fence at the top. There needs to be a “whole systems approach” designed to reduce demand, increase efficiency and effectiveness and find sufficient money to make health and social care (not living costs) free at the point of delivery of service.

    Britain’s State Pension is 29% of National Average Earnings compared with 100.6% in Holland, 94.9% in Portugal, 93.9% in Italy, 91.8% in Austria and 81.8% in Spain. The official definition of poverty is anything less than 60% of median household income.

    Given the correlation between income and demand upon the NHS it is hardly surprising that older people account for 4/5th of the expenditure. An estimated 1.3 million older people suffer from malnutrition costing the NHS £19.6 billion. There are five main causes of malnutrition, lack of money, lack of motivation, incapacity, lack of support and social isolation. A starting point may be to raise the State Pension from 29% of National Average Earnings to 60%. This could be offset in part by people who go on working beyond State Pension age continuing to pay National Insurance and not drawing their State Pensions until they retire – with phased arrangements.

    The aim would be to achieve the following financial outcome:
    • Cost of increasing State Pension
    from 29% to 60% of National Average earnings £82.4b
    • Saving on other benefits £37.05b
    • Clawed back through Income Tax £13.79b
    • Additional National Insurance from people
    over state pension age in work £ 3.9b
    • Saving on not paying State Pension until retirement £ 7.85b
    • 90% reduction in malnutrition amongst older people £17.85b
    • Reduced demand upon health and social services £ 7.3b
    Producing a credit of £5.52b

    The average cost of a Care Home is £29,270. With the increased state pension of £16,550, less the personal allowance (currently £27 per week), everyone would be able to contribute £15,092, leaving the Local Authority to find £14,178. There are currently 416,000 older people in Care Homes and it is anticipated this number would reduce, possibly by 20%, as a result of this “whole systems approach”. Therefore the cost of providing free social care would be 332,800 X £14,178 or £4.75b. We were already £5.52b in credit without all the organisational savings outlined below which will also be needed to reinforce the change and meet demand.

    Countless enquiries into “child abuse” and “adult abuse and neglect” have criticised agencies for not working together. Successive Governments have tried to encourage health and social services, in particular, to work together from Joint Funding in the 1970s to the pooling of budgets. However no Government has grasped the nettles of lack of coterminosity of geographical boundary and different funding streams and lines of accountability which has been the main impediment.

    This does not amount to the merger of Health and social care as this would further marginalise Social Work. Agencies have to work together in different combinations e.g Health, Adult Services, Leisure Services and Housing in respect of older people. And Children’s Services, Health, Education and the Police in respect of Child Protection etc.

    Local Government and Health Service re-organisations of the last thirty years have added to the cost and led to greater fragmentation. For example, Wales went from 8 County Councils and 37 District Councils to 22 Unitary Authorities. Wales had had coterminosity of boundary between Health and Social Services with a number of “All Wales Strategies”. Had the Unitary Authorities been based upon the existing County Councils there would have been immediate savings on the cost of democracy with the abolition of the District Councils and year on year savings as District Council Departments were merged into County Council Departments. In England the splitting of Children’s and Adult Services doubled the cost of senior management in addition to that of creating Unitary Authorities.

    During my time as a Director of Social Services my counterpart in Health ran nine hospitals, five of which were regional, community services and the Family Practitioners Committee (GPs) all with a management team smaller than is now found in every Hospital Trust. The abolition of Area Health Authorities has left a void of strategic planning and co-ordination.

    The answer may lie in bringing services together within County Council or Police Authority boundaries returning the Police and Health to local democratic control thereby achieving coterminosity of geographical boundary, common lines of accountability, common funding streams and economies of scale.

    There is sufficient evidence to get rid of the purchaser / provider split, introduced by Sir Roy Griffith in the mistaken belief that a mixed economy of care would force quality up and prices down, which was extended to social services by the 1990 National Health Service and Community Care Act, and increased management costs and, with respect to the NHS, led to an army of accountants chasing the same deficit around the system.

    There is just as much empirical evidence in respect of organisation, management and leadership as there is medicine and yet this is rarely applied in practice. Applying his unique “whole systems methodology” to a hospital in Holland, Christian Schumacher was able to get a 30% increase in output with higher morale and lower sickness levels. However many hospitals are still organised on the discredited “production line” model so that staff, often working in very stressful situations, do not see the outcome of their work.

    “Functional divisions” need to be removed from “patient pathways” by creating “whole task, right sized, multi-disciplinary teams”, able to “plan, do and evaluate” their work (which completes the learning cycle of constant improvement) with access to all the resources and expertise required. The number of tiers of management should be kept to a minimum. Appropriate levels of delegation can reduce time in meetings and employees need the “generic skills of their profession, specialist knowledge of their area of work and to be employed on the work which interests and motivates them.

    There is a need to invest in preventative measures which keep people active, mentally and physically, and prevent social isolation, social work intervention, community development and home care. Social workers need to be freed from “care management” and the “gate keeper” role of assessing the eligibility to specific services at a “component level” thereby enabling them to practice their skills in using relationship to bring about change in motivation, behaviour, inter-personal relationships and community support by various therapeutic techniques and counselling – reverting to a “mending” rather than the current “minding” service.

    The Statutory Agencies need to work with Housing Associations to develop “extra-care sheltered housing”. It is possible to put just as much nursing and social care into such developments, as it is traditional residential care, and the owner / tenant has his/her own front door, defended space and retains control over the essentials of daily living, which alleviate many of the harmful effects of traditional residential care and also reduce the risk of abuse which is greater when the victim is subservient.

    A more detailed, costed, report is available on Chris Perry’s “linkedin” page which suggests that free nursing and personal care is very affordable, within this “whole systems approach”, using increased pensions to lift all older people out of poverty as the catalyst to change.

    P.S I spoke at your Annual Parliament in Blackpool a few years ago and would be happy to do so again next year if you feel the ideas in this paper to be worth pursuing.


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