Postcard from the LGA Conference in Birmingham – BUURTZORG!

BuurtzorgLast week at the Local Government Association’s annual Conference I spoke at an event in the Innovation Zone about the work I have championed, as Chairman of the EELGA Improvement and Efficiency Board looking at the Dutch care system called BUURTZORG which is a successful Dutch model of care at home.

This is being explored in West Suffolk through a “Test and Learn Site”, one of only a handful in the England, in partnership with West Suffolk CCG, St. Edmundsbury Borough Council, Forest Heath District Council West Suffolk Councils and Suffolk County Council, with support from the East of England LGA and the UK Buurtzorg partner, Public World.

I was joined by Paul Jansen of Public World who are delivering the Buurtzorg project work in the UK and Kathryn Caley of SK Nurses who are delivering the pilot work in West Suffolk and for an hour we presented and debated aspects of the work. Afterwards I was approached by NHS England who were at the event to discuss how we might take the work further within the NHS.

The project is a step on a journey about a different way to delivery health and social care in our community.  I opened my words with the starkest fact I have at my disposal, in a Public Health exercise I commissioned in Suffolk last year looking at Suffolk in twenty years’ time if we do nothing Suffolk will need 792 additional acute beds based on current rate of admissions times its ageing population.  Now it’s clear that event with the £20Billion additional funding announced by the Government we are never going to see a doubling of the acute beds in Suffolk or across the country, so we have to find very different ways to support our residents in the future and this lies in improvement in the NHS, better integration across Health and Social Care, better Public Health, all of which will help but they allow will not solve the problem, the missing piece is a our communities and how services are designed and delivered in communities to better support the needs of an increasing cohort of older people who are living longer, which is great, but who’s needs must be dealt with very locally to stop them dipping into and out of acute NHS services.

The BUURTZORG Model of Care at Home
The Buurtzorg model grew from the vision of nurse Jos De Blok to tackle ongoing concerns in the provision of care, such as: the fragmentation of prevention, treatment, and care; the impact of demographic change; a shortage of care providers; lowering quality and increasing costs of care; and a lack information about the quality of outcomes in relation to the cost of care per client. Buurtzorg started in 2006 with a team of four nurses working closely with GPs and delivering community care services. By 2015 it had grown to over 9,000 nurses working in 800 teams working with 70,000 patients. The nurses are supported by around 45 back office staff.

The key to the approach is that the model empowers individuals – in this case nurses – to deliver all the care that patients need.  Nurses work in self-managing teams of up to twelve professionals who provide care for 40-50 clients in a specific locality. The nurses are ‘generalists’ taking care of a wide-range of patients and conditions. They are highly qualified; 70% to bachelors level. Their role includes:

  • Assessment of clients’ needs
  • Care delivery
  • Mapping networks of informal care
  • Coordination of care between providers
  • Promotion of self-care, self-management of conditions, and independence.

Buurtzorg is a non-profit enterprise and is 90% funded through health insurance, which is mandatory in The Netherlands. It has led to:

  • Overhead costs of 8%, compared to a national average of 25%
  • Lower staff turnover, lower sickness rates, high staff satisfaction
  • Lower costs of care per client, 40% less than national average
  • High patient satisfaction
  • 30% fewer A&E visits for clients
  • A € 9 million profit in 2014

 So can the BUURTZORG Model of Care at Home work in an English context?  
This is a key question that the coalition of health, social care and housing partners in West Suffolk are seeking to answer.  As I have said the partners have established a Buurtzorg “test and learn site”, one of only a handful in the country, with the support of ‘the system’ and its primary aim will be to

identify a way to adapt the model to our own context without losing the essential features of the Buurtzorg experience – the focus on mobilising and strengthening the capabilities of the client and the networks around them through self-organised teams of autonomous responsible professionals.  This last element is perhaps the most challenging, not so much to Local Government who over the past 7 years have started to empower its front lien staff more, but more challenging to the command and control elements of the NHS culture.

Website: http://www.eelga.gov.uk/innovation-programme/buurtzorg.aspx

News: http://www.eelga.gov.uk/news/west-suffolk-recruits-its-first-buurtzorg-nurses/

A very interesting week in Birmingham

Last week Councillors and Local Government officers from across the country gathered in Birmingham for the Annual Conference, with some exciting backdrops on the Agenda.

As always it seems the ‘U ‘ question (unitary councils bids such as Buckinghamshire, Oxfordshire and now Leicestershire lead the way) hangs in the air as it has done for a number of years. There was to be the maiden conference speech by a new SoS James Brokenshire MP and last but not least the previous week a key report was published jointly by the Health and Social Care and Housing, Communities and Local Government Committees. It makes for fascinating reading in the coming debate on Health and Social Care and indeed ahead of the much delayed Green Paper on Social Care now due in the Autumn a whole year after it was promised.

You can download it from the http://www.parliment.uk website by clicking the link below.

https://www.parliament.uk/business/committees/committees-a-z/commons-select/communities-and-local-government-committee/inquiries/parliament-2017/long-term-funding-of-adult-social-care-17-19/

Almost as a footnote last week, but no less interesting is an article by Tony Travers for http://www.lgcplus.com. Tony is one of the most respected speakers on Local Government finance and when he rings the warning bell its time to listen. the link to his article which makes for sobering reading is here:

https://www.lgcplus.com/services/health-and-care/tony-travers-nhs-is-on-course-to-consume-all-public-expenditure/7025020.article

On a personal note, I was delighted to get re-elected to the Conservative Executive of the LGA as what is known as an ‘At Large’ Executive Member rather than as the County Council representative for obvious reasons. I am delighted to join a tremendous senior Conservative team as we work to set out the Conservative Agenda at the LGA for the coming year.

Adult social care – a national or local Service

Just before I stepped down as Health and Social Care Spokesperson for the County Council Network I wrote the following for the Local Government Association which forms part of a think piece series ‘Towards a sustainable adult social care and support system’

https://www.local.gov.uk/about/campaigns/towards-sustainable-adult-social-care-and-support-system/2-adult-social-care-2

Adult social care has and continues to face significant challenges as a result of the current financial context, rising demand and evolving public expectations.

However, despite this, the notion of a national adult social care service is one that makes me break out in a cold sweat. I’ve read and heard from some people out there that adult social care is in the too difficult box for local government, with the easy option being that it be delivered on a similar size and scale to the NHS.

I would vehemently oppose such a notion. Local authority councillors and staff have worked hard to protect adult social care in the face of austerity and the significant reduction in public sector expenditure. For example, adult social care expenditure in counties accounted for 45 per cent of all service expenditure in 2017/18, excluding education, increasing from 42 per cent in 2015/16. Despite this, service user satisfaction levels remain high with social care in general, with 64.7 per cent being either extremely or very satisfied with the care and support services they received.

There is also an inherent risk in removing social care from local authorities that are legally bound to deliver a balanced budget year on year. Counties, and upper-tier authorities alike, have not shied away from making the difficult decisions required and re-routing money from the likes of transport, central services, and culture towards protecting these life-critical, people-focused, services. We have proven our ability to be prudent in a period of unpreceded financial cuts, often delivering more with less money. Following a similar model to the NHS, which continues to report regular and significant deficits on an annual basis, would most likely place additional and significant strain on the public purse.

As a councillor, I pride myself on the fact that I am democratically elected and the decisions that are made by me and my colleagues are accountable to the public we serve. I would be concerned for the future of democratic accountability if social care were to be delivered on a national basis, which would likely see it become subject to a similar democratic deficit as the NHS, something which was previously recognised by the Coalition Government through the creation of Health and Wellbeing Boards.

The Care Act made the promotion of individual wellbeing the organising principle of adult social care. Therefore, it would seem inconceivable to remove social care from local decision making on services that directly impact upon the health and wellbeing of every individual, such as public health, transport, education, plus housing and leisure in unitary areas.

What also seems clear to me is that a national adult social care service is incompatible with the ongoing impetus at both a national and local level to deliver care and support closer to communities and where possible away from acute settings.

For example, local knowledge will be essential to the Secretary of State for Health’s vision for reform that includes whole-person integrated care.

The personalisation agenda, including personal budgets and joint health and care plans, is built upon providing individuals with greater choice and control over the services and support that they can access locally. A ‘strength based’ or ‘asset based’ approach are used interchangeably. However, regardless of the label, a local social care service is ideally placed to work with adults, individuals, families and communities to deliver this agenda.

If we are to reduce the pressure on the hospital front and back doors a local approach is also essential. Ensuring that people are well informed of the best place to go to address their health and social care issues helps prevent attendances at A&E. The focus must be on maximising people’s independence, examining what outcomes a person wants to achieve and what is available locally to help them achieve that. Collaboration and coproduction with social workers who know the local area are at the heart of this approach.

This must be underpinned by the work of local authorities, councillors, community leaders and others to help build community resilience and capacity to support the most vulnerable in times of need. A prime example is the recent cold weather, which saw local people and groups supporting their communities by ensuring that vulnerable people could access medical appointments and also basic provisions.

It must also not be forgotten that care markets are unique, with differing needs and complexities existing not only in all four corners of England, but also within regions and local authority boundaries. A significant proportion of residential, nursing and domiciliary care is provided by small and independent providers. Would a national care service be able to interact with the swathe of providers that are either very local or regionally based? Or would they be able to respond at the pace that local authorities do if/when a provider falls into financial difficulty?

Many of the issues outlined above are recognisable across the country, but local solutions that are flexible and utilise the unique strengths of each and every community are, in my opinion, the best way to improve outcomes for local people.

Cllr Colin Noble
Health and Social Care Spokesman, County Councils Network

A conversation about Local Government

In the past couple of days Suffolk County Council have announced that we have asked Respublica, a policy think tank, to come and have a look at Suffolk to consider the next opportunities for making savings in Suffolk’s Local Government administration costs and thus how we can find money in the system to be spent on Frontline services.

This is what I sent out to Councillors, to District and Borough Council Leaders and the Police and Crime Commissioner and across Business, Voluntary and Health Partners.

Given the national and local changes and discussions underway it is the right time to look at the current arrangements for public service delivery in Suffolk. We have asked Respublica to examine the merits of an individual County bid for a retained and reformed two-tier system and this builds on our work in Suffolk to date, as explained in the briefing attached to the e-mail. Whilst Respublica will be working closely with the County Council’s leadership, given the collaborative approach across Suffolk’s public sector, local stakeholders will also be able to provide them with additional information, views and insight to inform the outcome of the work. If you have any questions about the work at this stage, please do not hesitate to contact me.

And that went with the attached Briefing Note: Suffolk County Council work on public sector reform:

Through collaboration, integration and devolution, Suffolk County Council has worked closely with public sector partners to further Suffolk’s collective ambition for thriving economies and thriving communities and to secure the best possible outcomes for Suffolk. Following the withdrawal of the Norfolk/Suffolk devolution deal in 2016, the Suffolk System has continued to drive that ambition and secure sustainable public finances, demonstrated for example, through Suffolk’s recent success as a Business Rates Retention pilot for 2018-19. However, medium term financial plans are clear that the combination of continued budget pressure and demographic demands mean that fundamentally different forms of delivery will be needed across public services in the future.

Central Government has been ambivalent in working with local areas (demonstrated, for example, through the number of places with and without devolution agreements); however, the Secretary of State for Housing, Communities and Local Government (MHCLG) has recently made four significant “minded to” decisions to create super-Districts in Suffolk (East and West), unitary local authorities in Dorset (2 unitary authorities) and Buckinghamshire (1 countywide unitary authority). This may signal a renewed commitment to public service reform by Government and is significant and consistent with Suffolk’s ambition and direction of travel for better local outcomes through different means of delivery.

The County Council is keen to ensure that Suffolk is best placed to work with Government on creating more sustainable local public services and better local outcomes. To do that will need a clear and compelling case that demonstrates Suffolk’s ambition and credibility as a place that delivers.

To help build that case, the County Council will be working with the think-tank Respublica to examine the merits of an individual County bid for a retained and reformed two-tier system. Respublica will provide additional expertise, experience and objectivity and has established itself as a leader in the policy area of public service reform and devolution, through demonstrable change. Its work with Greater Manchester Combined Authority (GMCA) (Devo Max Devo Manc) was the catalyst for the Government’s devolution deals and creation of Mayoral Combined Authorities across England along with the transfer of millions of central funding and associated decision making to these new local strategic authorities.

Last summer it worked with the County Councils Network (CCN) on an approach that placed counties as the building blocks for transformative devolution and public sector reform (Devo 2.0 The Case for Counties: Why a new model for local government in the counties is needed). This means that Respublica has a unique insight on public sector reform and devolution. That is why the County Council has asked Respublica to examine the merits of Suffolk making a bid to Government for a reformed system of local government as a way to unlock more local control and better delivery for key functions such as economic growth, housing and care.

To do this, Respublica will analyse Suffolk’s existing plans (eg, the devolution deal, economic strategies, joint strategic needs assessment) and focus on: the link between good governance and productivity; coherence of administrative boundaries and functional relationships. It will consider how a system could give Suffolk greater scope for enhanced strategic decision making over economic development and public service reform. To deliver this, it will use models and thinking developed for its work with city-regions, counties and devolved areas across the UK. The detail of the work is yet to be scoped in detail and it is expected to conclude early Autumn. Whilst Respublica will be working closely with the County Council’s leadership, given the collaborative approach across Suffolk’s public sector, local stakeholders will also be able to provide them with additional information, views and insight to inform the outcome of the work.

At what age do we become ‘old’?

Here’s the column I wrote for the EADT and the Ipswich Star newspapers last week:

 I’d like to begin this week’s column with a question.

At what age do we become ‘old’?

As language changes and adapts, we as a society are good at filtering out certain anachronisms. The use of the word “elderly”, for example, is less common now. But we frequently use such catch-all terms as “older people” which, after all, is so general as to be almost meaningless.

We are all ageing and I would claim with some confidence that we all want to age well. So, if we are not “older people” now, we will all fall within this category one day.

We know that more of us in Suffolk will be aged 65 years or over in the coming years as a proportion of the population. We’re also living longer, with the gap between male and female life expectancy closing.

In addition, Suffolk is a fantastic county, with incredible assets, so it is no surprise that many people enjoy living here, retiring here and ageing here.

Unlike many other parts of the UK, we are a county without a city. Many of our greatest strengths centre around rural, country living with the benefits this provides as we support one another and look out for our neighbours. We enjoy significant formal and informal networks of support that see old and young living and working together, bringing out the best attributes of supportive communities.

I would argue our rapidly ageing population can be viewed in one of two ways: as an insurmountable, growing threat to our health and social care services, or as a great opportunity to adapt, innovate and prosper as a county.

I see this as an opportunity to be a forward-thinking county that values and welcomes its growing older population.

No single authority, organisation or sector can create this environment alone. We must work together and engage our communities if we want to see meaningful, sustainable change.

The last 10 years have seen major change. We have seen a move from centralised control to more personalised support and care delivered in the community. The coming years will bring about increasing change to our health and care services.

Inevitably, we will be working later into life which means the nature and shape of the county’s workforce will change.

Our predominantly rural setting also provides a challenge to the way  we reach potentially isolated communities. But we are already seeing examples of this in abundance, from well established schemes such as the Debenham Project to emerging opportunities created by social prescribing.

Thanks to the foresight of our health and care teams, we are already seeing the benefits of  learning what works well elsewhere. In the west of the county, we are testing out the Buurtzorg model of integrated health and personal care delivered by small teams of self-managed nurses working in the community, based on an approach developed in the Netherlands.

One issue that is perennially in the headlines is housing; more specifically, the need for more housing that caters for the changing needs of the UK population. If we are to curb the trend of 30-40 year olds living at home because they cannot afford to join the property ladder at one end of the spectrum, and 80 year olds living on their own in a five-bedroom home at the other, we all have to act now.

But the need is wider than this: as we build and adapt our homes, we must ask ourselves if they are they hardwired for the needs of an entire population. Is the surrounding transport network responsive to the needs of an ageing society? Above all, are we providing affordable, shared space that encourages an active lifestyle at every stage of an individual’s life?

Ultimately, we need to provide support for those with more complex needs, while enabling others to remain active and independent, without the risks of becoming isolated.

When it comes to being connected, the myth of an older generation out of touch with modern technology is not borne out by the facts. Nationally, more than three quarters of 65-74 year olds and over 40% of those aged 74 and over used the internet in the last three months.

From open access at our libraries and other information points, to the investment in countywide broadband, our older population is more switched on to new media than ever. This is clearly not the case for all, but the many advantages this brings – from online shopping to connecting with family – are often a valuable antidote to social isolation.

Which brings me back to my question: what we mean by “old”? There’s the old cliché that you are only as old as you feel, and that age is just a state of mind; with people living and working longer, and the cultural changes that this entails, we may be moving  closer to a society in which we need to reconsider and redefine every aspect of what we mean by ageing.

Most of us enjoy better life chances, and a higher life expectancy, than previous generations. Though not without exceptions, this affords us the opportunity to think about ageing differently.

 

 

 

As winter approaches

Here’s the column I wrote for the EADT and the Ipswich Star newspapers a couple of weeks ago:

With temperatures noticeably dropping outside, we are on the cusp of the period that causes the most anxiety among health and social care professionals.

As the Leader of a county council, my staff are bracing themselves for the unknown, but putting robust plans in place to ensure any ‘winter crisis’ is kept at bay – as I’m sure councils are doing across the country. However, planning for the forthcoming period and beyond has been made more difficult; with storm clouds gathering between Whitehall and councils because of fraught debates over delayed transfers from hospital.

The context behind this leads back to the government’s much-welcomed additional £2billion for social care last March, showing it was listening to our concerns over the fragility of the social care system.

Councils have invested this money in making the system work better for patients, including raising care home fees, recruiting extra dementia nurses, and expanding rapid response services. This funding has helped reduce delayed discharges, and better supported the care needs of residents.

Initially, completely unrealistic targets were imposed on counties. Subsequently, 32 local authorities received letters asserting that if they do not improve discharge rates by November part of this £2bn funding would be withheld, or, equally concerning, diktats from Whitehall would be issued on how funding should be spent locally.

The imposition of targets and the positioning of NHS England has led to delays in agreeing details of the Better Care Fund (BCF), a further pot of cash for local areas to better integrate health services.

The concerns of Ministers are understandable. Rates of delayed transfers have continued to rise; a real issue for the health service but also a moral issue: no-one deserves to be stuck in hospital longer than they should do.

However, rising delayed discharges should be of little surprise when you consider the factors involved: the funding available for social care, rising demographics and demand, and, in particular whole system performance: two-thirds of delayed days are attributable to the NHS, not councils.

While Suffolk is not one of the 32 authorities that received a letter, just under half of those who were contacted are county authorities. Counties have faced a financial quandary unmatched in local government with 30% less funding per head of over 65s than in 2010 and face a £1bn black-hole in social care funding by 2020/21.

We must consider ways to use money in the system more effectively. This goes to the heart of why the current loggerheads between councils, NHS England, and the Department of Health is counterproductive and potentially highly damaging.

Counties have worked tirelessly with NHS partners to develop BCF plans, providing impetus to reduce demand. The prospect of this funding being withheld or placing it in a national body’s hands, could I fear, only worsen the situation. In this instance, centrally-led initiatives are no substitute for local knowledge and expertise.

Rather than short-term, centralist thinking, I believe we should channel our efforts into prevention and early intervention. People are living longer, meaning they are increasingly likely to have more complex conditions requiring greater levels of care.

This means there is also a need for personal responsibility as well – if people do things such as getting a flu jab, that will reduce the chance of receiving a serious illness and a visit to A&E. If people are unwell they should start by seeing their pharmacist and GP before visiting A&E, allowing those who really need emergency care to get it as quickly as possible.

Government may need to give health and social care additional funding in the Budget for the winter, but Ministers must also give local areas the opportunity to implement their BCF plans and deliver a preventative, community-based, approach.

Those 32 councils threatened with the prospect of having funding withheld must be given time to see the fruits of their labour. If not, investment by councils could go to waste and local partnerships with health will be permanently set back.

Fixing health and social care is not going to happen overnight. They are two very different beasts, multi-layered and steeped in years of bureaucracy and regulations.

That’s why whole-system reform is needed. We have failed to evolve the systems to match the demand, needs, expectations, and ultimately the money available to pay for them. It is this fundamental question we need to focus on in the forthcoming social care green paper, rather than who is to blame for delayed transfers.

Ultimately, it is revolution, rather than evolution, that is needed to unpick the systemic issues that drive the actions of both health and social care. But to make that happen, we need collaboration, not consternation.

Letter from the CCN to the Secretaries of State for Health & Local Government

fullsizeoutput_1cbeLast week I attended the National Children’s and Adult Services Conference in Bournemouth.  On the way down as Leaders from across the Adult Social Care Councils including me, received an email with a letter attached from SoS DH Jeremy Hunt and co-signed by SoS DCLG Sajid Javid about Delayed Transfers of Care, these happen when a person is medically fit for discharge form a Hospital and we are unable to put in place a suitable package of home or residential care quick enough, this is known in Health and Local Government as DTOC.

As winter approaches and with one of the worse Flu epidemic in the Southern Hemisphere seen in recent years (if you have not yet had the flu jab, I would recommend it, I paid £10 at my local chemist and apparently ASDA are doing them for £5) the NHS is extremely worried about the stress on hospital beds over the winter months, as they are expecting significant numbers of admissions for this simple but dangerous virus to vulnerable groups’.  So the need to feed up beds is important and there are two areas where local government is involved preventing people going to A&E in the first place and how quickly we can facilitate those who need a care package when they are ready to leave hospital obviously the more effective the system the more beds the NHS will have free to cope this winter.

The letter were somewhat condescending and effectively suggest we alongside the other 80 or so local councils responsible for DTOC are failing.  However it was a step back from the threats made earlier in the year about fines and direction of budget if the situation did not get sorted out.  Very DoH, not very DCLG but in this repsect DCLG is very much the junior partner to the might DoH.  During the course of last Wednesday at the conference it emerged that there were in fact three different letters issued, and our was the middle one not praising us but not summonsing us to Department of Health (DoH) as about 32 Councils will find themselves having to go before a panel of experts at DoH, and for experts read people who work in Whitehall, or more precisely civil servants who work in DH in Whitehall who will want to see plans for a lower DTOC target in those areas or they will re-direct monies spent of Adult Social Care to hospitals which will not deal with the issues and probably make them worse.  Adult Social Care cannot be fixed by a summons from DoH, it needs careful partnership working on the ground in each area surrounding a hospital. .  At the conference, we referred to these as naughty step letter and which one you were on – a very flippant comment given the seriousness of the issue but given the patronising letters, as if our social work teams are not working hard to provide the care packages, which they are, its the right term to use.

The issues are complex and the impression you get from the letters is that its entirely Local Governments fault and so DoH can swoop in, divert money to hospitals and all will be right with the world, sorry but this is nonsense.   Fundamentally Local Government needs funding to provide the care, it’s as simple as that, and the threat is that if local Government does not improve then it will have funding withdrawn is worrying.  this is not about simply demanding more money for Local Government has stepped up and made the savings the Government has called for but there comes a point.  Across the county grown up discussion with Hospitals and Clinical Commissioning groups are building a long term system to handle discharge and withdrawing money will not improve that one bit, quite the reverse in fact.

So, on behalf of the County Councils Network on Friday I wrote to both Secretaries of State pointing out the position of CCN member Councils and our concerns.  In Suffolk we work closely with our Acute hospitals planning prevention, avoiding having to go to A&E and when people are admitted discharge planning starts straight away, in West Suffolk the hospital’s enlighten CE Stephen Dunn has contracted beds in a Care Home with nursing to provide people a different setting to recover, what used to be called Convalescence.  As our population ages we are going to need to see a return to this sort of step down care, from our hospitals.

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