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12 My Journey Fulbourn Hospital circa 1983 Images of Care 2010 So where are we now? The case for change is as compelling as ever: Population demand Costs and funding Customer expectations Three commissioning challenges: Arranging the right service for each individual Getting the right mix of services and capacity in each locality Working together on things that are too big for individual customers, providers or commissioners

13 Demand for care and support is increasing amongst all age groups There will be a significant increase of those aged over 65.. Numbers of over 65s in England with care need..and, the number of disabled adults will also increase Numbers of working age adult in England with care need The cost of meeting this demand is unsustainable The projected cost of personal social services will rise Projected cost of personal social services leading to a funding gap of 6bn in twenty years time Personal social services funding gap

14 Expectations are rising for older people and younger disabled people. There are now 17 million baby boomers marching towards retirement with a high set of demands and a clear expectation of what they want in retirement (Age Concern 2004) Attitudes and expectations of public services of older people now are very different to those held by people who will reach old age over the next 35 years Disabled People s movement has also emphasised the need to ensure that people can take control of their own lives and there are concerns over the fairness, equity and transparency Local variation and inequalities between self-funders and Statefunded people exist Local discretion means that some local authorities will fund people with moderate needs, whereas others will fund only those with critical needs. This can be perceived as unfair People find the current means testing system unfair It is difficult for people to anticipate and plan for the costs of care In a poll, 1 in 5 people were unable to describe what they understood social care to mean Majority of people believe that social care is provided for free by the NHS Local variation and the lack of a single source of advice causes difficulties

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17 Objectives For Today To hear about the journey ahead. To ask questions about post election national policies and priorities. To contribute to the discussion. To exchange information. To consider what it all means for us all? Hope Street Centre for Health and Social Care Development William Greenwood Director and Senior Consultant, Hope Street Centre Tel:

18 Challenges in Social Care Budget pressures - acute pressures on local authority budgets arising from demographic changes; Fragmented funding - with direct and indirect funding spread across local government, DH, DCLG and DWP, through benefits and allowances; Fragmented commissioning local authorities / 152 PCTs and increasingly individual budgets; Fragmented supply side and lack of scale and investment capacity - inability of Small traditional providers to integrate new technology (such as assistive technology ) or home adaptations, case finding and call centre monitoring to their service offerings. Absence of diversity of service offering - little real choice in terms of quality and innovation; Lack of fit for purpose home or near home accommodation - inadequate supply of appropriate tenanted/owner-occupier accommodation and inadequate supply of service or support into tenanted/ owner-occupier environments (home care, telecare, day centres, respite and rehabilitation). Challenges in Social Care Another View? 4

19 Predicting the Future can be Dangerous - A Health Warning! (Predictions of Lord Kelvin, president of the Royal Society, ) "Radio has no future." "Heavier than air flying machines are impossible." "X-rays will prove to be a hoax. What is Happening in the Health and Social Care System? Ones to watch... Commission on Social Care. The economic climate and public sector. Constant demand pressures on the local care systems. Health and Social Care system reforms including GP based commissioning. Innovations such as Total Place.

20 Policy and System Drivers Delivery of personalisation and increased choice and control for the citizen and user of services A more integrated approach across all public services with a focus on achieving sustainable communities. Strategic planning and performance assessment driven by outcomes. Policy and System Drivers Achieving cost efficiencies and savings to the public purse with a relentless pursuit of value for money, maximising the benefits from investment. Ongoing innovation and improvement in a highly risk averse climate. A huge cultural shift in service design and delivery, leading to transformation in housing, health and social care services.

21 Planning: The English Context Overarching principles Central Government performance framework Performance framework for LAs and their partners NHS performance framework Public Service Agreements Departmental Strategic Objectives Local Government White Paper NHS Operating Framework Delivery priorities (performance indicators ) PSA/DSO Indicators National Indicator Set NHS Vital Signs Delivery mechanisms LA Business Plans Local Area Agreements PCT Operational Plans The Economic Climate

22 Demand Pressures/ QIPP Growth history Trajectory Flat spend scenario % % of current revenue limit x Spend gap, b Trajectory based on range derived from 5.5 7% average annual growth seen in previous years data based on commissioning framework as of January 2010 EoE SHA area revenue limits, bn 06/11/10 06/11/ /8 2008/9 2009/ / / / /14 System Reforms The Department of Health has introduced the ambition for World Class Commissioning. The commissioning framework for health and wellbeing sets out how services should be shaped including: Moving services to be more personal and sensitive to individual needs, and supporting independence and dignity;

23 System Reforms Re-orientating services to promote health and wellbeing, investing to save (in prevention etc to reduce future ill health costs); and Focusing more strongly on commissioning services that will achieve better health, across health and local government, working together to promote inclusion and tackle health inequalities. Total Place Whole area approach to commissioning/ delivery of public services. 13 national pilot sites. 63 LAs; 34 PCTs; 12 Fire & 12 Police Authorities + Social Sector. Covers older people/ children/ addictions/ housing/ worklessness/ asset management/ offender services etc.

24 Opportunities Keeping people out of hospital. Enabling people to remain independent. New technologies. Working with primary care (GPs/pharmacy). Rehabilitation services Stroke etc. Prevention and life style? Probabilities in the Future A common failing is making predictions rather than attaching probabilities to possibilities! Regeneration medicine will become a major component of healthcare. Predictive modelling of biological behaviour. Wearable computers & intelligent clothing. Digital butlers i.e. home smart sensors. Electronic circuitry connected to nerves and tissues.

25 Conclusions The future is highly unpredictable. Nevertheless, it is important to think about the future; those who do prosper. A good way to think about the future is to imagine different futures/different partnerships. In health - care systems will increasingly be concerned with chronic disease and prevention not acute disease. Hope Street Centre for Health and Social Care Development - Thank You.

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27 Nursing started in Chaos Nursing Indicators; Future Challenge 676,547 nurses on register 17.15% 55 yrs & over 13.89% years 34.38% 40-49% 12,000 reduction in overseas nurses

28 Realities Nursing faces Revalidation NMC Changes in Immigration Economic downturn Ageing population & global impact Recruitment to profession Care Homes; a good career choice? 30-35% Sector staff turnover 40% leave within a year 60% leave within 2 years

29 Is this where Nurses want to be? 6 The Stark Reality Europe Age % 18% Age % 44% USA Age % 26% Age % 34% Japan Age % 15% Age % 52% East Asia Age % 20% Age % 40% Latin America Age % 29% Age % 30% Source UN

30 The Nursing Challenge Ageing populations > long term conditions Reduction in labour market Reduction in available revenue Less family care support Cultural challenges migration 9 Future Challenges Demographic impact Costs of care Grey vote Loss of tax revenue Intergenerational tension Reduction in global Migration care workers Global migration of Care provision Need shared solution 10

31 Opportunities New Realities New ways of working Greater plurality of provision Personal Health Budgets New Healthcare worker? Registration National Minimum of training HCA workforce Opportunities New Realities Develop leaders as specialists in Long Term Facility Care Coherent Sector Voice influencing national scene Engage in Research Agendas not just leave to the academics Develop career paths which bring specialism to forefront of nursing agenda

32 Opportunities New Realities Responsive flexible services Out reach from Care Home hubs Flexible respite and short term rehabilitation Flexible careers matrix across voluntary, social care, independent and NHS The world in 2050 Chronic disease overtake communicable disease as global challenge Less family carers More older woman poor, widowed, single living alone Labour shortage 14

33 Nursing in 2050 New hybrid of Practitioner Support Fewer Advanced practitioners Flexible consultants / Freelance Flexible Careers Portfolio careers across sectors Highly educated Partnering patients 16

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36 Total Place How can we get improved outcomes at less cost through: greater collaboration; a deeper engagement with citizens; and a genuine focus on place? How does the money flow? What do citizens want? What are the service pressures? Developing, testing, and refining a series of propositions

37 How providers might prosper in a Time of Adversity The gathering storm Or The new hope A conflicted presentation

38 Three hot topics 5 minute SWOT analysis of the Coalition programme for government How we are going to reduce public expenditure Re-orientating your business to thrive in big society 5 minute SWOT analysis of the Coalition programme for government

39 Qualifications Not all 400 commitments Just the ones that seem relevant to providers of health and social care The strengths Devolution of financial control and authority coupled with general power of competence to local government could create opportunities for innovation Guarantee to increase spend on the NHS in real terms and a softer approach to cuts means more money maintained in the system Easily accessible local data will enable improved planning by providers More proportionate approach to vetting and barring could save money

40 The weaknesses Localisation of planning at a neighbourhood level could make controversial development more difficult Relying on more GP led commissioning could be a mistake difficult to get local agenda properly aligned with small business priorities Further delay in deciding how to fund long term care The opportunities Re-focused, better funded Sure Start for areas of higher deprivation allied with payment by results Open up, simplify and make cheaper government procurement Patient choice within the NHS will stimulate a market for non-statutory providers Greater priority for preventative health care in areas of higher deprivation General focus on payment by results is good news for effective providers

41 The opportunities Extending the roll out of personal budgets creates a new market of customers Voluntary insurance and partnering schemes for funding long term care will create a new generation of customers with different purchasing power and expectations The threats Shake up of benefits system is likely to challenge people with intermittent but enduring conditions The transformation of Monitor into an economic regulator of the NHS will want to prove its rigour early

42 The threats Shake up of benefits system is likely to challenge people with intermittent but enduring conditions The transformation of Monitor into an economic regulator of the NHS will want to prove its rigour early How do you save lots of public money?

43 Act like Canadians Canadian budget deficit of 9%+ in 1994 turned into a surplus by 1997 Cuts of 20% in public expenditure aligned with modest tax increases Possibly an easier strategy for a nation half the size of the UK Did result in longer waiting times for hospital admission and higher infection rates (due to over crowding) UK Public Spending

44 UK Public Spending UK Public Spending

45 UK Public Spending Start with the first 6billion Departmental contributions in Value Department for Education 670m Department for Transport 683m Communities and Local Government 780m CLG Local Government 405m 320 million from Child Trust Funds Business Innovation and Skills 836m Home Office 367m Ministry of Justice 325m Law Officers Departments 18m Foreign and Commonwealth Office 55m Department for Energy and Climate Change 85m Department for Environment Food and Rural Affairs 162m Department for Culture Media and Sport 88m Department for Work and Pensions 535m Chancellor s Departments 451m

46 Some observations on cuts Pre election, the Conservative party identified 2billion in IT efficiency targets which could be easily realised In reality this turned into 95million i.e. a 95% overestimate Efficiency is much harder than expected This first wave of cuts will impact on large numbers of interim managers in government departments Subsequent waves will need to reduce permanent employee numbers elsewhere in public services Some observations on cuts Local government was the biggest loser 19% of this first 6.2billion is coming from this area Around 311m from education, 309m from transport and over 500million individual grants Abolition of ring fencing around 1.7billion of central government grants from 2010/11 At this stage no reduction in the 29billion of formula grant

47 The timetable May 25 th 6.2billion cuts announced Emergency Budget taking place next week on 24 th June 2010 will set the big picture or general direction Comprehensive public spending review in October will identify more precisely specific areas of cost reduction, and the means by which some will be achieved In between all of this we the public will be chipping in our ideas for how to save money How much is going to go? The public number is 20% over either 3 years or the life time of the parliament. 20% over three years equates to year on year reductions of around 7%. 20% over five years equates to year on year reductions of around 4.5% Cost of part nationalisation of Lloyds and RBS and full nationalisation of Northern Rock around 45.8billion money recovered on sale and debt repayment.

48 The spending review 45 days (including weekend working) is a very short time to work out how to reduce public expenditure by 20% in 3/5 years. The spending review in October is probably the more significant event and will contain much of the detail of how reductions are to be achieved. Cuts are a bit like quality we measure them in terms of the detail of their impact. The spending review The forthcoming Spending Review will involve more than the allocation of resources. While it will rightly focus on reducing Britain s record deficit and restoring sound public finances, it will also provide a platform to consider new and radical approaches to public service provision

49 The spending There are two review agendas here. Reduce The forthcoming the public Spending spending Review deficit will cuts involve in more expenditure than the allocation and sale of of bank resources. While it will rightly focus on assets reducing Britain s record deficit and restoring sound public finances, it will also Reduce provide a public platform expenditure to consider new forever and - fundamental radical approaches change to public in expectation service of provision what government does, establish a lower tax economy The spending There are two review agendas here. Your challenge is to: Reduce The forthcoming the public Spending spending Review deficit will cuts involve more than the allocation of resources. Ride in expenditure out While the it will first and rightly a sale focus well of bank on as assets reducing Britain s possible record deficit and restoring sound public finances, it will also Reduce provide a public platform expenditure to consider new forever and - fundamental Adapt radical approaches your change offer to public in to expectation service succeed of provision what government does, establish a lower in the tax second economy

50 The spending review Challenge departments, local government and delivery partners to consider fundamental changes to the way they provide vital services: better targeting of interventions greater range of service providers challenge state monopolies exploit the synergies between delivery bodies promote responsibility by shifting power, funding and accountability into the hands of individuals and frontline professionals The spending review Challenge departments, local government and delivery partners to consider fundamental changes to the way they provide vital services: better targeting of interventions greater range of service providers challenge state monopolies exploit the synergies between delivery bodies promote responsibility by shifting power, funding and accountability into the hands of individuals and frontline professionals Means testing of universal benefits such as child benefit, only delivering Sure Start services to people in deprivation

51 The spending review Challenge departments, local government and delivery partners to consider fundamental changes to the way they provide vital services: better targeting of interventions greater range of service providers challenge state monopolies exploit the synergies between delivery bodies promote responsibility by shifting power, funding and accountability into the hands of individuals and frontline professionals Positive and negative incentives to increase the role for the private sector, and voluntary sector with a public preference for small voluntary organisations The spending review Challenge departments, local government and delivery partners to consider fundamental changes to the way they provide vital services: better targeting of interventions greater range of service providers challenge state monopolies exploit the synergies between delivery bodies promote responsibility by shifting power, funding and accountability into the hands of individuals and frontline professionals A return to non-compulsory Compulsory Competitive Tendering?

52 The spending review Challenge departments, local government and delivery partners to consider fundamental changes to the way they provide vital services: better targeting of interventions greater range of service providers challenge state monopolies exploit the synergies between delivery bodies promote responsibility by shifting power, funding and accountability into the hands of individuals and frontline professionals Consolidate housing benefit and other welfare payments? The spending review Challenge departments, local government and delivery partners to consider fundamental changes to the way they provide vital services: better targeting of interventions greater range of service providers challenge state monopolies exploit the synergies between delivery bodies promote responsibility by shifting power, funding and accountability into the hands of individuals and frontline professionals Self Help Community Sprit Lower expectations of the state

53 The spending review Set out its plans to reform the welfare system Restrain the costs of public sector pay and pensions The more that can be achieved in these areas, the more the Government will be able to do to protect jobs and spending on frontline public services The spending review Set out its plans to reform the welfare system Restrain the costs of public sector pay and pensions The more that can be achieved in these areas, the more the Government will be able to do to protect Reduce the cost of welfare limit access to incapacity benefit, very strict application of all benefits relating to unemployment jobs and spending on frontline public services

54 The spending review Set out its plans to reform the welfare system Restrain the costs of public sector pay and pensions The more that can be achieved in these areas, the more the Government will be able to do to protect jobs and spending on frontline public services Combination of de-facto salary/t&c caps and more aggressive outsourcing The spending review Set out its plans to reform the welfare system Restrain the costs of public sector pay and pensions The more that can be achieved in these areas, the more the Government will be able to do to protect jobs and spending on frontline public services Offering to trade lower salaries, and poorer terms for job security

55 The spending review 9 big questions Depending on the answers it could fundamentally change the role and nature of the state Feeds into key theme of localisation local services, commissioned locally, reflecting local priorities and ethos A smaller state but bigger citizen driven activity The spending review Is the activity essential to meet Government priorities? Does the Government need to fund this activity? 9 big questions Does the activity provide substantial economic value? Can Depending the activity on be the targeted answers to those it could most fundamentally in need? How change can the activity role and be nature provided of at the lower state cost? How can the activity be provided more effectively? Feeds into key theme of localisation local Can the activity be provided by a non-state provider or by services, commissioned locally, reflecting local citizens, wholly or in partnership? Can priorities non-state and providers ethos be paid to carry out the activity according A smaller to state the results but bigger they achieve? citizen driven activity Can local bodies as opposed to central government provide the activity?

56 Adapting to the big society Adapting to the big society 10 ideas for how adaptation could be achieved.

57 Adapting to the big society 10 ideas for how adaptation could be achieved. Seek to build alliances and partnerships with smaller local/ community groups and organisations so that they become part of your delivery offer The spending review 10 ideas for how adaptation could be achieved. Look to develop formal partnerships with GPs to assist them in expanding the range of their local offer reablement, GP supervised step down etc

58 The spending review 10 ideas for how adaptation could be achieved. Develop support offers which formally utilise family members at low or nil cost The spending review 10 ideas for how adaptation could be achieved. Develop housing solutions which hardwire in technology and actively promote a sense of individuality and independence whilst increasing client density

59 The spending review 10 ideas for how adaptation could be achieved. Seek to be a partner with local authority provision and NHS provider functions which are emerging into social enterprise status they do not have to be competitors The spending review 10 ideas for how adaptation could be achieved. Proactively seek merger partners which add expertise and credibility as well as scale

60 The spending review 10 ideas for how adaptation could be achieved. Have fully worked up strategies of community engagement people power is the new doctrine The spending review 10 ideas for how adaptation could be achieved. Apply effective measurement of services outcomes and quantify in terms of cashable efficiency

61 The spending review 10 ideas for how adaptation could be achieved. Develop service offers which work for individual procurement which are based on a mixed funding stream (private resources and state resources) The spending review 10 ideas for how adaptation could be achieved. Work on the basis that local is the new regional but.. customers will still expect you to price like a national

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64 30 minutes 3 tasks Identify the top six barriers to successful complementary/joint working with the NHS What changes could the new government make to overcome them? What are the two most significant and specific contributions that social care services can make to the effective running of the NHS? 30 minutes 3 tasks Decide who is feeding back Be ready to present your thoughts in a maximum of 5 minutes Critique from the expert panel and your colleagues

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