ADASS budget survey points to a needed revolution

Earlier this month, the Association of Directors of Adult Social Services published there budget survey for 2015. As usual Ray James’ and the team’s report is incredibly insightful and helpful, but I think points us towards a step change in approach that is needed.

The report presents a clear picture of a sector that is on top of it’s budget, and while it has some concerns about the future, it is by no means panicking. Let’s pick out some highlights:
– Directors of Adults Services in England have committed to £1.1bn of savings this year (taking demographic pressures into account). Whilst most are still through “efficiencies” £192m will be from straight forward reduced services.
– Almost half are fully confident of delivering their savings this year, the rest (bar 1%) partially confident.
– Almost half state there have been no or minimal impact of the savings to date, with only 3% saying quality of care is lower.

They are more concerned about the future, but still manageable:
– 84% have full or partial confidence in 17/18 savings
– Only 17% expect quality of care to deteriorate
– And they have what could appear to be strange confidence in some big changes – for example prevention spend is anticipated to shrink at double the rate of the rest of the service this year (6% vs 3%), however an increase in preventing need scores highest for the area of savings for both 15/16 and beyond.

The sector clearly sees the pressures and that efficiencies are running out, so, where does this confidence come from? I know John Bolton will be depressed but not surprised to hear that the answer to the source of confidence can be summarised in one word – INTEGRATION. Directors of Adults are looking over the fence at the green grass of NHS resources and see a solution. Since 2010/11, NHS funding has increased by 19bn (9%) while social care funding has decreased £1.6bn (11%).

Who do they need to convince to make this a reality? It isn’t Simon Stevens. He has put in place mechanisms for funding to be shared (Better Care Fund, section 256 agreements). It is local NHS leaders. The argument is that social care plays an essential health preventative role that all will recognise and fund. Integration and increased prevention were the clear priorities of savings area (71% and 73% rating them as “high”, with the next on the list being at 53%). However, it is clear they aren’t convinced yet. A good example of that is winter pressures. Every hospital trust director and CCG accountable officer I have asked has said the biggest local issue is social care availability. Yet less than 6% of the winter pressures funding last year was given to councils.

So, what is needed to convince them?

I would suggest two tactics
1. Start measuring different things. I know it is hard, but we must collect evidence of impact and think more about the effect of changes we are making. An uncharitable reading of the report could conclude it doesn’t matter if you are planning service cuts if quality of life will not be lower – in fact, why not cut deeper. We need to think, budget and categorise savings differently. In one of our recent surveys we found that 98% of Chief Execs and Council directors plan a significant or heavy focus on managing demand (Inflection Point report), compared with 25% in 2011 (Changing the game report). Cutting services or supporting less people is not a bad thing
2. Directly focus on winning people over. This is where system leadership gets real. It will be different in each area, but you could do worse than prioritise it down to about 1000 people – the Chief Exec and FD of hospital trusts and the Accountable Officer and FD of CCGs. In a recent survey of health and care system leaders in one locality, the one thing they strongly agreed on was that there is not a shared view of the root cause of transfer of care delays.

It is still fair to say “if integration is the answer, you’ve got the question wrong”. Perhaps a better question is “sustainable health and care will require some big bold local decisions – who is it who really needs to agree what, and what evidence will they need?