Over the last week our 'View from the Grassroots' series has been looking at an interlocking set of NHS 'reform' plans in one area, Calderdale, trying to make sense of what is proposed.
Even those dubious about what 'integrated health and social care' could mean for the NHS, recognised that social care needs fixing. But will these plans achieve that?
In Calderdale, the plans for ‘integrated’ health and social care state:
“the traditional model of care and support is no longer sustainable and...encourages dependence...evidence indicates that people in Calderdale spiral into a cycle of dependency and escalating support needs.”
The Leader of the Council, Cllr Tim Swift, disagrees:
“This is not a fair description of how social care now operates in Calderdale... there is good evidence of the progress we are making. For example, Calderdale has the second best performance in the region in keeping people out of care homes until it is absolutely necessary. We have put a strong emphasis on investment in reablement services. Even in the current financial crisis, we have been able to keep eligibility criteria at moderate – if we were working in the way described in this document then we would no doubt have had to join the 88% of local authorities who have raised their criteria to substantial or critical.”
The Calderdale Outline Case proposes taking the power to assess social care needs away from Calderdale Council. In future the councilwould merely give ‘information and advice’ to people who ‘will often make use of their own resources to self-fund care and support’.
It would ‘create a responsive local market’ for social care and somehow ‘inspire and oversee care providers’ by a system of payments based on outcomes such as keeping patients out of hospital.
The Better Care Plan suggests that Calderdale Council will avoid “statutory health and social care assessment" by releasing "health funding” - although quite what that means is pretty unfathomable from the incoherent report.
These proposals seem to accelerate and intensify existing trends in social care. A social worker commented:
“Gone are the days when councils undertook in depth assessments and provided the appropriate services in house. It’s privatisation, services which have already gone to tender have lower care standards and rely on poor pay and working conditions. They are not monitoring providers of people who have personal budgets. Where is safeguarding in all this?”
Exactly how this fragmented, market-based approach to providing social care is supposed to benefit patients is not clear.
Alice Mill, a carer, said,
“I care for someone with cerebral palsy who finds managing his carers and finding an appropriate home equivalent to running a business.”
Why is it the business of local authorities and the NHS to create a local market in home and community-based care services?
Personal Health Budgets
The Better Care Fund plan and the Strategic Outline Case are full of phrases like ‘person-centred integration’. What this appears to mean is a plan to merge existing ‘personal social care budgets’, with new ‘personal healthcare budgets’ (PHBs).
Personal health budgets were first proposed by Labour peer Lord Darzi in 2008.
In 2009, the Royal College of Nursing said that personal health budgets could be used to justify making cuts to community nursing. There were huge concerns that they could lead to an undermining of collective, comprehensive healthcare.
They were trialled in an inconclusive pilot.
The Coalition government slipped through the legislation for personal health budgets during a parliamentary recess in 2013.
The Dutch experience of Personal Health Budgets has been that they led to escalating costs and widespread abuse, with the result that the Dutch have radically reduced their availability.
In March 2014, the Nuffield Trust suggested that personal health budgets would require some NHS services to be scrapped and this would reduce patient choice.
Despite all this, the new system of PHBs, introduced on 1 April 2014, is now available to chronically ill patients living at home. They can use their PHB to buy in an agreed package of “continuing health care” services.
Better off Clinical Commissioning Groups will be able to offer higher personal budgets. The government denies Personal Health Budgets could be used to create two-tier healthcare. They point out that patients can’t use personal healthcare budgets to pay for primary medical services such as care you normally receive from a family doctor, or for acute care services such as A&E. Instead, they are for specific aspects of ongoing care, such as psychological therapy or pulmonary rehabilitation package of care. However If patients want to buy extra continuing health care, on top of that provided for in their PHB package, they can do so privately out of their own income.
Calderdale Clinical Commissioning Group told us it estimates around 60 patients in Calderdale are currently eligible for a personal health budget. This is out of a population of around 213,000. It seems a bit weird to design a whole integrated care in the community system around such a small number of people.
Personal health budgets are being rolled out to a limited group for now, but the government is keen to extend them.
Patients’ use of their personal budgets would be key to the creation of a “local market” in home and community-based continuing care services, according to the SOC and Better Care Plan.
Patients in some parts of England can already buy needs assessments, social care and continuing healthcare services from online care marketplaces. Hertfordshire County Council has developed an online Care Market, in partnership with the cloudBuy company and Serco.
Northamptonshire County Council has also formed a partnership with cloudBuy, and the consumer loyalty company Grass Roots that is open to everyone who needs social care, not just personal budget holders.
cloudBye and the semi-privatised NHS Shared Business Services are launching a Care Marketplace service for the NHS and continuing health budget holders. Greater Manchester Commissioning Support unit (one of the shadowy organisations ‘supporting’ local NHS commissioners, and itself soon to be privatised) will pilot it. This will allow the purchase of a range of continuing healthcare services, such as visits from a nurse, help with shopping or grip rails or other pieces of kit.
These online purchasing systems already have the facility to allow top-up payments to be made if the social care budget runs out.
And what will patients be buying with their budget?
Somewhat weirdly, treatments purchased with PHBs do not have to be evidence-based treatments approved by NICE (National Institute for Health and Care Excellence).
During a small scale PHB pilot in 2009 patients used personal healthcare budgets to buy things like theatre tickets, frozen meals and complementary therapies. These things are no doubt pleasant. But why should NHS funding be used to pay for them?
This seems to be part of a trend of poaching money from the (supposedly ring-fenced) NHS to spend on other services. It can only weaken the ability of the NHS to provide an effective, universal, equitable health service.
The clinical commissioning groups plan to pay for social care and continuing health care using a system of outcomes-based payments - for instance, success in keeping people out of hospital, “re-abling” people so they can return to work etc.
The trouble with this is that it provides a perverse incentive to avoid treating the most ill patients.
A health care market has a tendency to ‘cherry pick’ patients and treatments, and limit its offering to commercially rewarding populations and neighbourhoods (ie people without long term illness, people living in middle class neighbourhoods where poverty-related, chronic health problems are rarer).
At the 13th March Calderdale CCG Governing Body meeting, a GP warned that this
“...needs careful governance to avoid obvious cherry picking issues.”
An ideological drive to turn citizens into consumers, destabilising and undermining the NHS
These obvious cherrypicking issues are intensified by evidence from the widespread use of personal social care budgets, that only a small number of better educated, motivated patients benefit.
Personal health budgets are part of an ongoing process - arguably pursued by all three mainstream political parties - to turn citizens into consumers. Professor Dexter Whitfield calls this process a “mutation of privatisation”, that is advanced by the Coalition government’s extension of community and individual “rights to buy” public services.
An independent study by the University of Glasgow and Kings College London found last month that the Government’s personal health budgets scheme was ‘wholly inadequate’ and being driven by consumerist ‘ideology’ rather than hard evidence.
One of the authors, independent consultant in social care Colin Slasberg, told Pulse Today:
‘A small number of people with the confidence and skills to manage this will garner what
cash is around. They will create good success stories that ministers will say shows how good they are, and GPs will be blamed for the fact they are not taking off for everybody.’
This worries GPs, who are likely to have responsibility for overseeing the PHB scheme when it rolls out to all patients with chronic illnesses in April 2014.
The ideology behind personal health budgets can be described as “user choice rights”. These ‘rights’ are an essential step in privatising public services and resources. They are rights which are exercised individually. They undermine collective rights that require thinking about other people than yourself, that build social solidarity and give meaning to political activity as a process of deciding how best to use society’s wealth and resources for the common good.
Like many of the apparently technical “tweaks” that Calderdale and Huddersfield’s “Right Care” proposals aim to introduce - virtual wards, predictive modelling, risk stratification, shared digitised confidential patient data, the use of telecare and telehealth, and personalised care in the community itself - personal health budgets are designed to destabilise and fracture public NHS provision to pave the way for further marketisation and privatisation.
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