10 DASSs on ‘what next for adult social care?’

I’m lucky to have worked alongside some inspiring Directors of Adult Social Services (DASSs) over recent years, people whose leadership I respect and opinions I value. It was to some of these people that I turned to recently to help me take stock and answer the question ‘what next for the sector?’

Over the course of several weeks I spoke with 10 DASSs and asked them about their own experience of the last few months, their reflections on what had worked well at a local level, and the challenges and opportunities that now present themselves. We will be publishing a proper overview of these reflections soon, but in the meantime a summary of key points from my discussions is presented below.

Strategy:

• Local system response: – this has been a huge success, largely due to the removal of funding accountability and because local systems had a clear common purpose.
• Local government reorganisation: there is a renewed focus on single tier unitary councils. A structural change to remove an unhelpful focus on organisations and silos is now more likely.
• Dominance (command and control) approach of health: this has undermined the voice of local government, and risks unravelling years of work trying to shift to community or asset-based approaches.
• Focus on beds: the sector has seen community hospitals repurposed as intermediate care beds. There are now a broad range of questions about the wider use of beds going forward – for example, what should happen to nursing, residential and community hospital beds?

Demand:

• Demand modelling: this proved to be unhelpful. It took up a large amount of energy and focus and simply drove the desire for more beds which ultimately were not needed.
• Future winter modelling: this must be system wide, move away from a traditional bed focus and instead consider the capacity required within the community.
• Demand management: there will be a significant surge in post Covid demand that the sector needs to understand and manage, including discharged demand, displaced demand and latent demand.

Finance:

• Financial impact on councils: this will be huge, with many councils forecasting significant savings required from adult social care in future years.
• Financial uncertainty: this is being exacerbated by a loss of operational, financial and performance grip, with in year budgets needing to be revisited, nervousness about ongoing funding of the hospital discharge model, derailed savings plans and the risk to recovery of monies from self-funders.

Workforce:

• Frontline practice: unprecedented change has been seen in frontline working, including increased collaboration with partners, flexible working, use of technology, changed working hours, and more ambitious conversations with people about the risks they are prepared to take to remain independent at home.
• ‘Care’ brand: this has taken a positive step forward in the national consciousness, leading to improved recruitment and enthusiasm for the sector.
• Wellbeing: staff have been ‘done to’ through this period rather than being consulted and involved in changes. There is now a need to win hearts and minds and improve wellbeing and support as staff transition out of the crisis.

Market:

• Care homes: demand for placements will now reduce but we are unlikely to see short term market rationalisation.
• Short term support: local government will need to support the market to avoid business closures and subsequent pressures on supply and price.
• Reshaping the market: the opportunity exists to repurpose the role of residential homes and improve support in the community and at home.

Community:

• Volunteers: there has been a fantastic response from volunteers especially in supporting the shielded population. There now needs to be a dramatic shift in rhetoric from ‘vulnerable and protect’ to asset-based independence if the sector is to avoid creating high levels of dependency from this cohort.
• Social prescribing: there is now more evidence that this is effective and important. Hopefully that this will give health the confidence to look beyond care homes and discharge to assess as the core discharge options.
• Partnership: there is increased recognition of the significant value the voluntary and community sector (VCS) has played. There is now ambition for the VCS to continue to step up and become equal partners with health and social care.

Technology & Data:

• Governance: the sector has made significant in-roads into data sharing across organisations. This needs to be maintained, with the focus shifting to providing rich insight and intelligence at a person and system level.
• Culture: the sector has broken down cultural barriers in the use of technology to deliver services. Previously technology was often counter cultural and blocked, but it has now proven to be effective for professional contact and reducing isolation.

System Relationships:

• Collaboration: greater understanding of different roles and professions across the system has improved trust, empathy and led to improved inclusive ambition (for example acutes asking local government to lead on getting people out of hospital and back home).

Transformation:

• Pace: years of change has been delivered in a few weeks through rapid ‘test and learn’ improvement cycles and decision making. This now needs to be maintained.
• Ambition: the central government narrative is about recovery in weeks or months, which is too narrow framed. The sector needs to think about where it wants to be in 2024 and set the strategic ambition to get there.

The views and ideas above reflect not only the huge, system-wide impact the pandemic has had, but also the opportunities it has presented to ‘bounce forward’ rather than just bounce back. Realising this opportunity will be complex and require a sustained sector response, but everyone I spoke to sees this opportunity as real. Our summary of what this means for the sector – the five key questions now facing adult social care – will be published soon; watch this space.