Q We now come to our final witness session of the day. We will be joined by Stephen Chandler, who is the president of the Association of Directors of Adult Social Services. We will also be joined remotely by Gerry Nosowska, who is the chair of the British Association of Social Workers. We have until 5.15 pm for this session. I remind Members, because one of our witnesses is joining remotely, to be clear about who they are directing their questions to. May I ask both witnesses to introduce themselves for the record?
Good afternoon, everyone. I am Stephen Chandler. As you said, I am currently the president of the Association of Directors of Adult Social Services. ADASS is a small charity that represents directors such as myself. My day job is director of adult services in Oxfordshire—up and down the country. It is probably important to say by way of context that I have only worked in the public sector. I left school and started my training as a nurse. The first 20 years of my career were in the NHS. I reached trust board level via a route of joint commissioning. The second half of my career is in local government, so in a way I am living proof of integration, if there was one.
I am Gerry Nosowska, and I am the chair of the British Association of Social Workers, which is the professional body for social work in the United Kingdom. We have around 22,000 members. I am here to represent the voice of social work, and our experts by experience who have worked with us.
Q May I start with you, Stephen? This may start to build on your dual professional career in both local government and the national health service. The Bill tries to ensure that much of the important data that flows between the two, and other services within the health and social care system, is more effectively and efficiently used for the benefit of patients and their outcomes, so how could a new provider dataset best meet the needs of local authorities in particular in meeting their Care Act duties?
It is a really good question. We see the importance of bringing that collective data together in one place at every level in the stratified system. If you take the integrated care system, at the macro level it is really important for population-based planning. My local integrated care system covers Buckinghamshire, Oxfordshire and Berkshire—colloquially, BOB—and for some conditions dealing with it at that footprint is really important. Having data, for example, around cancer care and some of the specialist mental health services is really important.
The first thing that I did this morning was to chair a call looking at urgent care activity in our local system, and it was really important for the staff from the community trust and social care, as well as the acute staff, to be looking at a single view of the citizen—the patient—in that instance. We have done a lot of work to get there already. Again, this is about building on some good foundations, but it is critical for practitioners to do their job to have that data there, flowing readily, as well as for us in the planning and commissioning sense.
Yes, please. The link between health and social care data is obviously essential, because health care impacts on people’s lives and social lives, and social determinants impact on health. Joining those things up will help us to have a much more holistic picture, which is what social workers are interested in. For social workers, what we really want to understand are the trends, the gaps, and the barriers to wellbeing. In practice, having that data and that understanding—ideally a really local understanding—is important.
We would want to see social workers and experts by experience input into the kind of data that is collected, with an understanding in particular of under-met or unmet need, so that we can become more preventative, which is another aim of integration, and we have information about people who might fall outside of statutory responsibilities—self-funders, for example. We know that there is a real need to understand much more about the pressures on carers. This is an opportunity to think about how we can build more fairness locally through understanding the inconsistencies in people’s experiences and outcomes. We also have a need to understand the impact of digital developments on people—how to ensure equity as we move into a wider range of working. Another hope would be that, ultimately, our health and social care leaders will be able to be more proactive using the data, because very often it feels like we are on the back foot.
Q I, too, did joint commissioning roles in Oxfordshire at one point—so, only the best.
Every project that I have seen or witnessed on integration—joint commissioning; joint collaboration—has fallen apart in the end because of accountability for the money. A finance director in a local authority has to account for its budgets, and the finance director and accountable officer of a health authority ultimately has to account for their budgets. If agreement cannot be held at that point, those projects fall apart.
We heard earlier that we still do not know any detail on the tariff or money flows as a result of changes in the Bill—changes that will come into place in April. We also have the better care fund outwith the Bill, and this week’s announcement of a major change in funding is also outwith it. I wonder, with your ADASS hat on, how can you now help the Government to get around the problem for organisations regarding accountability for the money so that they do not fail?
Again, that is a really good question. To be honest, a real challenge for those of us working in both health and social care is that uncertainty and delay in knowing the financial envelope we are working with. The announcements this week help to provide some clarity of what the future funding arrangement is likely to look like but, of course—from a local government point of view—until the spending review confirms the final settlement later this year, we will not know.
Some practical examples of how to mitigate or manage some of that uncertainty clearly come down to how much you are able to put together—and feel confident to put together. I suspect it was probably there in your day in Oxfordshire, but Oxfordshire has a large pooled budget arrangement—some of it completely risk-shared, but some of it not. That reflects the confidence and experience we have in using that money together. If I were not here providing testimony to you, I would be chairing a joint commissioning executive. In Oxfordshire, across health and social care, we have responsibility for more than £500 million in health and social care expenditure.
We are talking about continuing to build on some really good relationships and experiences that have existed but, rather than allowing them to evolve because individuals—either at a system level or a personal level—believe it is the right thing, it becomes policy and direction. I think that the success for us has to be looking at where systems have been able to resolve some of those challenges. I am still working with my CCG colleagues in Oxfordshire around what we believe the better care fund will look like, having signed the agreement at the beginning of the year. That is about us becoming much more involved and therefore much more confident in each other.
You will appreciate that ADASS members are constantly providing reassurance and at times caution to our elected members on how far we could and should go in relation to sharing and using our resources. Some of the developments in the Bill around the establishment of integrated care partnerships fully provide a vehicle for some of that greater transparency and greater opportunity to look at the problem, the challenge and the opportunity from a place, and then from a system, point of view.
Yes, indeed. Without giving away too much personal information, my wife and I have a joint account. We each have our own accounts. She is not here, so I will say that I think I have the authority on the joint account, but if she was here she would probably say that she has.
The point I am trying to make is that a lot of this works on the formal agreement, but as much of it also works on the trust and confidence you build in those relationships. However, you cannot take away the facts, as you said. Equally, my elected members are very clear with me that I am responsible for ensuring that Oxfordshire County Council’s resources are being managed and used in the way that they have approved.
The principles that underpin successful discharge are, quite simply, a person-centred, strength-based approach to enabling that individual to get back, preferably and ideally, to their own home, in a timely manner, with the level of support that they need to continue the recovery that will have started in the hospital but will not have finished in the hospital.
Where we have got that process right—I think the discharge to assess arrangements have really helped us in this—is by clarifying that the destination for discharge, for the majority of patients, has to be home. It is pathway 1—“Home First”, as it is often described—with the appropriate reablement support to maximise the recovery. That is good for the patient; it is good for us in local government, because it reduces the level of ongoing care needs in many cases; and it is good for the NHS, in that it frees up acute hospital beds. Those are the principles.
The way you successfully do that is by ensuring that the focus is on the patient and getting the patient—the citizen—to their home, not on the organisational form and who is responsible for it; in fairness, we all are. Discharge to assess has helped us to clarify “Home First” or pathway 1, and it has provided for some of those systems where one of the stumbling blocks was the resources to make that happen.
The challenge we have, though, is that we have introduced “Home First” at a system level nationally at a time when demand, linked to covid and the unintended consequences of covid, has really impacted. I reference my first meeting this morning, looking at acute pressures in Oxfordshire. We pride ourselves on getting people home, and “Home First”, but when I was chairing that call I heard myself saying, “We need to move people into some interim beds”, because I needed to create capacity in the acute system. I am hearing that coming through from director colleagues up and down the country; we are making less than ideal decisions for people because of just how much demand there is in the system. Let us be very clear: good discharge is discharge home, to your bed, with the support to enable you to maximise your recovery.
Yes, please. I completely agree with Stephen on the principles behind discharge to assess, and we have good experience within social work of it working when there is clear shared responsibility and the person is kept at the centre of it. We also have evidence from our members of the potential for rapid discharge to assess, without real advocacy and potentially without the involvement of social work, to lead to some undermining of people’s rights around potentially being placed in a more restrictive environment and potentially struggling to have access to their family. It is partly about resourcing, but it is also about the ethos of human rights and people’s right to be heard and to have choice, and then having the practical backing to follow things up well.
I think that people with experience of social care and health want to have a really clear and transparent process. For that to happen well, we still need some safeguards around that transition. It is a complex moment in people’s lives, and I would want to see social work involvement in the guidance around that. But we also need to be thinking, if we want people to have more of their care closer to home, about how we rebalance resources—this relates to the previous question—by making sure that there are incentives for the resource to be put into community and local support and not just into the most urgent matters.
Could I come back in? One thing that I omitted—it was remiss of me—was that we also need to never forget the importance of the support for carers, particularly around hospital discharge. All too often we are focusing on the individual in the hospital bed and the need to get them out, but we also need to ensure that we are not overlooking or not giving due regard to the role of the carer in that. If I could ask you to do anything, it would be this. Can you just ensure that the emphasis on the role of carers and how all of this is going to help the role of carers is brought through? Without carers, the health and care system would disintegrate rapidly.
Q What confidence do you have in the discharge to assess model? Obviously, there have been pilots since 2016, but a lot of this was accelerated through the pandemic. That may be a good thing, but it might also be a bad thing, in that we have now to look at data in a very short timeframe. I served on the Health Committee over a decade ago, and during those discussions around tables like this, we used to talk about the Liverpool care pathway and how that was a good model to be following, until it unwound spectacularly and its local delivery was not as was thought in Committees like this. I wanted to ask what your view is on discharge to assess. You have mentioned carers and ensuring that we take into account the need for carers to be able to cope with any rapid discharges. Are there any other concerns that you might have about the model that should be taken into account?
You are right: discharge to assess and, indeed, the “Home First” model of three pathways is not new. It has been around and used up and down the country for a decade or so now, so there are some well established services that you can draw some really good data from. Before I was in Oxfordshire, I was in Somerset, and we did a lot of work in the Somerset system to develop “Home First”, because our delays were really poor. We saw significant improvement in the outcomes for patients in the first instance. We then saw significant improvements in the flow from the acute hospitals, and I would say we also saw some significant benefits to the local authority in relation to the commitment it had to individuals on an ongoing basis.
I have been out of that system for over two years, but the work that it has done since then to take that even further is phenomenal, and I would encourage you to talk to some of the health and social care professionals in that system. One of the hallmarks of the system is that it does not rely solely on health and social care professionals. It has brought what it refers to as community agents and village agents into the hospital to help with discharge. It has got the voluntary sector as an equal partner. It is helping the individuals beyond the health and care needs that they have in leaving hospital.
I personally believe that discharge to assess is a robust and positive model, and I am hearing nothing to the contrary from director colleagues. What I am hearing from director colleagues, though, is real anxiety about conclusions that might be being drawn from the very point you made, which is that we have tried to evaluate discharge to assess in a very short period of time, and at a time when demand and pressure on the service has been at its most acute. Remember that it is not just the physical demand on those services that we have been experiencing; we have been working on an assumption that there is likely, at any point, to be an immediate surge in the demand for acute services, so we have been working to try to ensure that there is always capacity behind us should a further wave—either a local or a national wave—occur. We have been, up and down the country, operating systems at a pace that I have never seen before, as a result of covid. I would be cautious about drawing out any strong opinions around discharge to assess from an evaluation that was done during that covid period. For me, it is the only model that really helps people leave hospital in a timely manner.
I do not know about any of you, but as I get older and hospital admission becomes more likely, I want that hospital admission to deal with the acute need that requires it, but I want to go back home as quickly as I possibly can and to be able to continue to regain the independence I had. I do not want to become reliant on the local authority for all my support, which is why that reablement support at discharge is so critical.
Gerry probably wants to add to this, but the multidisciplinary approach that has a social worker and the local authority at its heart, building upon not just the professional expertise we bring but the relationships with our communities, our voluntary sector and our social care providers, is critical to that success.
Yes, please. The issue with getting out of hospital is not about getting out of hospital; it is about getting your life back and getting back to your normal life. We know that reablement can be a really important part of that. The persistence, co-ordination and attention to the impact of a transition from hospital to home is something that social workers can really help with, and I do not think we should underestimate how potentially complex that can be. It is not just a question of somebody going back home and picking up where they left off.
Having really good support rapidly following up is absolutely essential. We have concerns about evidence of either inappropriate support or lack of support, support that has not been there or follow-up that has not happened. I would want us to be careful about checks and balances here.
Q May I start with you, Gerry? Do you think the provisions in the Bill will bring about genuine integration of health and social care, which is something that has been talked about through quite a lot of my lifetime in the NHS? If you could only change one thing in the Bill to get the best outcome from it, what would it be?
I think that this can achieve some strengthening of integration if it is not just a reorganisation that sucks in energy and resource, but a change that is absolutely about relationship, trust and understanding of local services, and it leads to a flow of resources and attention to that idea of home and community. There is potential, absolutely, but we have seen efforts to build integration before. What makes them work, certainly from a frontline point of view, is parity of esteem, trust, understanding and recognition of expertise, and relational time together.
One question I have is about how the integrated care partnership and the board have the appropriate input, the right people in there and the right people engaged, so that those relationships can really build, bearing in mind that we might be talking about quite a large area. We also have to make sure that from the point of view of the person who needs help or care, it is about their local community and neighbourhood. If I were going to change something, I would want to make sure that there was lived experience and social work expertise at the heart of those integrated structures.
Q A common theme that we have heard throughout both days of discussion is about how to capture the voices and the understanding from such a broad landscape within health and social care. In Scotland, we have been working on integration since about 2013. It is clear that in some areas it is massively successful and in other areas it is struggling. A lot of it comes down to relationships, understanding and willingness to step forward together.
May I ask you the same questions, Stephen? Do you think it will improve integration? What is the one thing you would change?
I do believe that it will improve integration. As I said earlier, anything that helps those people who have yet to be convinced that integration is a good thing or provides them with some of the roadmaps for putting integration into place is great. From a local government point of view, strengthening the role that local government has in relation to the health and wellbeing of its citizens in the way that this does is good. I look forward to the refined guidance around the roles that health and wellbeing boards will have, because when I talk to my leader, I emphasise to her the importance that that gives her, as an elected member who chairs that board.
On whether I would change anything, we risk focusing a lot on either people who are acutely unwell or the elderly. From a local government and social care point of view, we work with people across their life course, including working-age adults, many of whom often have very complex underlying health and care needs. Recognising the need to ensure that health and care systems work well for a 25-year-old with learning disabilities who is trying to achieve his potential, or to help somebody with a severe and enduring mental illness to maintain their employment and therefore their accommodation, is really important.
Unfortunately, those voices are not always as obvious in what we are doing, but they are so important. I have been quoting this a lot of late, but each and every one of us is just one accident or life-changing illness away from needing that. We all recognise that we may need healthcare to deal with it, but very few of us think that we may then need and want the support of social care. In my case, if I had an accident or a significant stroke on the way home, I would need help maintaining my family. All the things we take for granted are only possible for a lot of people through the help that local government and social care provide, but doing that together with our health colleagues offers even greater opportunities.
Q As you say, we often think of the frail elderly when we think of social care, but is it not the case that the need for social care among working-age and younger people—you talked about learning difficulties and disability—is a growing and under-serviced area?
It absolutely is. If you think of a young person with a complex health need associated with a learning disability, we need to work together to ensure that we are allowing them to maximise their potential while managing the risk associated with their health needs. For somebody who is coming out of the criminal justice system, maximising their potential to reintegrate into society, get a job and get a house is only possible if we work together. That is why integration must be much more than just a focus on the frail elderly.
Q So is there a bit of the Bill you would want to change? If we let you write an amendment, what would you write?
Q I have a couple of questions for Gerry. Your briefing made it clear that your members had a concern about discharge to assess; a clear majority said they did not support it, although the numbers are quite small. Would you say that is an accurate reflection of your overall membership?
It is a genuine concern, yes—partly because, as Stephen was saying, it was rolled out very rapidly, at scale, during an unusual and very pressured time. Social workers have often been involved in those transitions, and very well, to advocate and to ensure that the person’s voice is heard and that people do not get lost somewhere in the system or forgotten, but the concerns are around the potential weakening of that social work role.
Not everybody will need that, but I advocate for a social worker being available to anybody who might need that kind of co-ordination, therapeutic support and advocacy at the point of such a major life transition. We want a review of the model, but we also have concerns about just taking out wholesale all the elements around notification of social care and everything that was in the care Act. A lot will hinge on what the statutory guidance says about this. We must make sure we do not lose people in the system, because there is always an incentive to free up a valuable resource in hospital, but our statutory job is to promote wellbeing.
Q You mentioned the review; your briefing said that you had expected one to be undertaken back in March, and it has not been done yet. Do you know why that has happened?
If I could help, I am aware that the Department of Health and Social Care has undertaken a review of some discharge to assess arrangements. It is not a national review, but I think about eight separate systems have been subject to a review. I have not seen the outcome of it, but a review of a limited capacity has taken place.
Q I will ask a supplementary. We have spoken about discharge. I have a particular interest in how we develop the system by the use of ICBs and ICPs in order to highlight prevention. Very often, admission is the result of issues before, and as Stephen highlighted and Gerry alluded to, carers and families all take the weight of the stress when somebody is admitted, and when somebody is discharged and needs reablement. What does the Bill do, or what would you like to see in it, to help prevent people falling ill?
The Bill reaffirms and formalises the requirement to plan very carefully for the population at a place level first, and then at a system level. In doing so, it sets up an integrated care partnership with a clear set of objectives, based on the population. Of course, it emphasises the importance of prevention as a way of helping people remain healthy and well for longer.
In Oxfordshire, we have set up our shadow partnership, and one of the areas we are looking at is our out-of-hospital support—particularly how we can avoid the need for hospital admissions. Again—this goes back to a point I made earlier—in doing so, we are looking at how we as a system can contribute individually, and therefore collectively, to reducing crisis and therefore the need for hospital admission. It has changed the tone of the discussion from, “Isn’t that an NHS responsibility, whether primary care or secondary care?” to, “How can we do better for our population?”.
You might say, “Well, hold on. That sounds like a very subtle change.” Let me be clear: some of these subtle changes really do make an impact. Coming back to an earlier question about resources, this also enables us to have the conversation around the prioritisation and impact of those resources. Instead of saying, “Here is the county council’s budget plan and here is the NHS’s”, we can ask how we make best use of that collective resource. The Bill helps by formalising that and providing some additional structures and focus on that.
The Bill is helpful, but it will be interesting to see how it works where, perhaps, systems have not had positive relationships or have had a more adversarial approach. I was really lucky in Somerset, because the emerging ICS there was coterminous with the local authority. It was a single provider. It was perfect in a way. I am in an ICS now where there are three different population groups. We know some ICSs have significantly more.
The opportunity is there to be grasped. This provides a fantastic focus if it can be ensured. In fairness to colleagues, the focus seems to be “start at place and work upwards”, rather than “start at system and work downwards”, in order to make really good differences to people, particularly around hospital admission avoidance. It also gives me, from a local authority point of view, greater leverage to challenge my NHS colleagues around their investment in secondary care and community care resources, because that area has, unfortunately, seen significant reductions over the years.
Prevention is always undermined by the resources moving into urgent and acute needs. In practice, social workers are not able to do therapeutic, restorative support work that they would be able to if they had the time to spend with people who need that. There is a fundamental resource issue that the Bill does not address directly, but it may help with the potential for pooling resources. Again, people in the community do not care whether it is a health or social care resource. If there is a need emerging that can be responded to, and preventive work can be done, it should happen without health and social care arguing about exactly whose purse it comes out of.
There are some really successful examples of reablement and preventing avoidable hospital admissions. We know it is possible. Scarcity does breed competition rather than collaboration, so that is something to think about. As for what the Bill might also do, the partnership strategy ought to have a very strong preventive element to it, and that needs to be dug down into locally—into particular communities, neighbourhoods and streets. That is where you really need lived experiences. I have a question about the regard that the integrated care board would have to that, and the potential for a wonderful, collaborative partnership strategy around prevention to be disregarded because of an acute need. I was listening to Robert Francis, and I think his suggestion that there be a written explanation to a local community if that happens is very good.
Q Just one question to both of you, if I may. First, thank you for all that you and your members have done and continue to do. I say that as a former council cabinet member for adult social care and health and public health. I know the shadow Minister will share that sentiment. When I was doing that job some years ago and I was not quite so grey, the director of adult social services with whom I worked was a lady called Marian Harrington, who had been working in adult social care for a long time. A key point that she always emphasised to me was the importance of a close working relationship between the NHS locally, social care and the local council, particularly on discharge, but also on the ongoing care of people with multiple needs who were receiving social care. She would always say to me that although the framework was important, equally important were the culture, the behaviours, and trusting relationships between organisations in the framework.
I will turn to Stephen first and then to Gerry. We have sought to be permissive rather than prescriptive in this Bill. Have we struck broadly the right balance, or are there areas where it might need to be tweaked, either in legislation or in guidance?
Your director colleague was absolutely right. I think that you have got the balance right in relation to permissiveness. I worry that the guidance does not prescribe directly how we should develop that culture, but having worked as long as I have, I realise that you cannot prescribe how relationships are formed and how cultures work. You have to create the conditions for success. Some of those conditions are in the Bill. I have talked about some of them in relation to the pooling, the boards and the assurance methodology. What has to be absolutely clear—and I am hearing it clearly, so it is not that I have not heard it—is the importance of seeing this as a vehicle for meaningful change to people’s lives, not a restructuring of health and social care. Rather, this is a vehicle for improving the lives of people in communities and systems, and for allowing health and social care professionals to maximise their individual abilities for that collective good. In a way, there is a duty on me as a leader in the system to create that culture and environment.
You have not gone into the area of assurance, but for me it is really important that when assurance looks at a system, it looks at the leadership and how that leadership translates the freedom, the permissiveness, but also the accountability, clearly. The feedback I am hearing from our members is, “We favour the permissive approach that is taken in this.” We would not say that the tolerance should be changed one way or the other.
Apologies, I think I lost my connection for a moment, so I might repeat some of the things that Stephen said. On the balance between permissive and rigid, we have an interest in the consistency of opportunity and outcomes for members of the population. Areas face different challenges, so it is important that locally there is flexibility around how those challenges are met. What will hold those models together are the principles of ensuring transparency around decision making; the involvement of lived experience and clinical expertise in both social care and health; and real local accountability. Certainly, more local community decision making, planning and work, and less centralisation, is much more in tune with responding to the lived needs of people and their day-to-day priorities.
HCB47 UK Freedom From Fluoride Alliance (UKFFFA)
HCB48 Alcohol Health Alliance, Collective Voice, and NHS Addictions Provider Alliance (joint submission)
HCB49 Royal College of Obstetricians and Gynaecologists (RCOG)
HCB50 Alcohol Focus Scotland
HCB52 The Health Foundation
HCB53 Vision Care for Homeless People
HCB54 The Richmond Group of Charities
HCB55 Pam Richards
HCB56 British Medical Association (BMA)
HCB57 Camurus Ltd
HCB58 General Medical Council (GMC)
HCB59 British Association of Social Workers