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Adult Social Care

Discussion in 'Speaker's Corner' started by No1newts, Apr 29, 2019.

  1. No1newts

    Capodecina

    Joined: May 24, 2009

    Posts: 19,139

    Location: North East

    I just wonder if we will ever get a sensible solution to dealing with the issue of increased adult social care costs.

    https://www.google.com/amp/s/amp.th...elling-social-care-provision-on-state-pension

    Now I'm not necessarily saying everything Green says is correct but the gist, that the elderly and soon to be elderly (baby boomers) need to pay their way in old age. We will be moving into a situation where more will be out of work than in work and a generation which prospered massively on the boom, are now expecting the generation being hammered by the bust to pay for them.

    What's worse is we know this is an issue but whenever either party beings it up it gets politicised to try and grab power (see the Labour response) when this is potentially such a huge issue it needs cross party consensus to address it.

    What are people's thoughts? I despair and think we will stay stuck in limbo until it hits a wall as there is no compromise in politics these days.
     
  2. Orionaut

    Soldato

    Joined: Aug 2, 2012

    Posts: 6,388

    As the old saying goes,

    If I were you I wouldn't have started from here.

    Back in the 60's, pretty much everybody I knew lived in an extended family. One household even included a Great Grandmother.

    This crisis in social care is driven not so much by people living longer but rather by the idea that families should look after one another has fallen out of fashion.
     
  3. No1newts

    Capodecina

    Joined: May 24, 2009

    Posts: 19,139

    Location: North East

    I agree that doesn't help but in these extended families the majority would be of working age. So in my mother's family you had 7 children working (3 or 4 grandkids) and 2 elderly dependents.

    Putting this into these days terms, I will use my own family situation, you will have two dependents and two potential carers. Plus retirement age for potential carers is now 65+ meaning we will be expected to work rather than be able to care. It's a similar story with young dependents, people are having less kids (less potential carers) and working longer for net less making it almost inevitable the state will need to at least partly help.

    I agree familial care is less common but I think it's more a necessity of the times than a choice, or at least one as much as the other.
     
  4. The_Abyss

    Capodecina

    Joined: May 15, 2007

    Posts: 10,719

    Location: Ipswich / Bodham

    It is good to see that the discussion has already picked up on something other than just cost this early, as the issue of social care is multi-faceted and cannot be solved efficiently through funding alone.

    That said, increased funding must be part of the solution, and today's situation where people cease paying NI once they reached state pension age is utterly perverse, given that NI funds far more than just the state pension but also contributes to health spending.

    As yet another example of over-complexity and lack of joined up thinking though, the proposal that Green's supported suggests a range of funding methods, one of which is to tax winter fuel payments. So that's money that's been raised through general taxation that's now administered and paid out to certain people (over a certain age) that would be taxed again in turn and some money returned. Another example of bureacuracy going mad.
     
  5. Dis86

    Capodecina

    Joined: Dec 23, 2011

    Posts: 19,404

    Location: Northern England

    I think it's another symptom of something strange we're seeing in society in this country. People no longer expect to have to care for their dependants.
    You typically see it with mum and dad who have kids but then don't want to change or restrict their lifestyle so have grandmas and grandads pick the kids up every morning to either look after them all day or take them to school. Then they too pick them up from school and either take them home for a few hours to feed them or drop them off back at home.
    Where I live on a morning is hilarious. It's a constant stream of old people driving in to the area followed by working age people driving out.
    Later in life at a time when maybe grandad has passed and grandma is getting on she would traditionally move in so that she could be looked after. Now however she's just shipped off to a home because again, caring for her would mean that same change in lifestyle which nobody is willing to sacrifice these days.

    People want to have their cake and have society pay for it whilst they eat it.
     
  6. FortuitousFluke

    Mobster

    Joined: Jul 7, 2011

    Posts: 3,316

    Location: Cambridgeshire

    Former domiciliary care contracts manager here. I used to manage about 40 dom care providers for a County Council. I could write a bloody essay on this subject but I thought I'd weigh in on the above post just to highlight how defined the shift away from care in the family has become. Towards Christmas time dom care agencies will send out letters to next of kin asking them to detail what the plan for Mum and Dad is around the holiday period. Basically, do they still need to send the carers in. It is disturbingly common for families to indicate that the care is still needed, only for the carers to rock up and find that the service user is seated round a dinner table with 12 family members. And this isn't a balls up, they genuinely expect the carer to carry out their duties because nobody around the table wants to do it. We're not talking intimate personal care necessarily, it could just be minor meds administration, or helping the family member to eat.

    The authority I worked for was just trialing a community based approach when I left, it's based on the Dutch Buurtzorg model that operated a more holistic, outcomes based approach within a geographical locality using community nursing resource. In my opinion this is the route towards providing better and more efficient care. There are aspects of this around the Country, Wiltshire use a flawed outcomes based model, Northamptonshire are using an "if you're there and you're qualified" approach to cut down on overlap, and obviously my old authority are trying the locality based model in a limited fashion, but it needs investment and balls to move away from a time and task based model and it's really hard to get the leeway to do it when the hard steer from Councillors is to cut costs.

    The above only deals with community provision from LAs too, that's without touching on the need for closer partnership between health and social care, better adoption of prevention instead of reactionary approaches and the need to find a way to deal with spiraling costs in the nursing and residential markets.
     
  7. dowie

    Caporegime

    Joined: Jan 29, 2008

    Posts: 38,316

    I guess on the financial side people seem to want others to pay, proposals such as changing the rules for domiciliary care so that the home isn't exempt (as per residential care) would seem to be quite sensible and make things fairer yet generate emotive headlines about a "dementia tax" and people worrying about "their" inheritance.

    Something like that inherently rewards/incentivises the situation where family members instead live with and help take care of an elderly relative not to mention encourages people to downsize in retirement freeing up housing resources.


    What does the Dutch model do differently out of interest? I know you've mentioned community nursing - how does that differ to the current practices around the UK?

    Also what is the prevention angle you're referring to here? Is that in reference to day to day care or pre-empting the need to perhaps adapt a home or move to residential or something?
     
  8. Rroff

    Man of Honour

    Joined: Oct 13, 2006

    Posts: 61,157

    Slight tangent but my mum has been caring for various elderly, usually fairly distant, relatives and/or long time acquaintances where the direct family has effectively abandoned them to social care because they don't want the inconvenience, etc. while that isn't the way my mum was brought up or her instincts, etc. with the result, which isn't her motivation at all, that a number of times she has been written in for a bigger share of any inheritance going - and almost every time the more direct family suddenly start taking interest in the 1-2 weeks before the person passes away then kick up a stink when they realise they've been all but written out of the will sometimes specifically expressed that it is because they've not been there when care was needed.

    The whole thing is a mess though at every level of society none the less a few generations ago it was much more normal for things like only one parent to be working freeing up the other to look after family - these days that is a luxury an increasing number of people can't afford.

    EDIT: Dunno if anyone can find a study for the UK and that goes back a bit further - for some reason I can't seem to think of good keywords for searching - the closest I could find is a study from the US going back to 1970:

    https://www.pewresearch.org/fact-ta...-balance-work-and-family-life-when-both-work/
     
    Last edited: May 13, 2019
  9. Rilot

    Don

    Joined: Oct 18, 2002

    Posts: 19,268

    Location: Wargrave, UK

    I don't think this is a symptom of people not wanting to change their lifestyles, rather a symptom of the rising costs of housing. No longer can a family afford a mortgage on a single salary (unless that salary is very high) and so both parents need to work. In my experience, employers don't care about childcare issues and although they are expected to consider flexible working, that is all they have to do; consider it. This leave people with 3 choices: Downsize the house. Pay a child minder to do the collection etc. Ask grandparents to do it.
    After my boy was born both I and my wife asked our respective employers for flexible working so that one of us could do the nursery runs etc. We were both rejected.
     
  10. Rroff

    Man of Honour

    Joined: Oct 13, 2006

    Posts: 61,157

    Yeah certainly a big factor - for some reason I'm struggling to find studies and a good graph for the UK of the changing nature of that work division.
     
  11. Dis86

    Capodecina

    Joined: Dec 23, 2011

    Posts: 19,404

    Location: Northern England

    You missed a 4th choice. Plan ahead and purchase a house that you can comfortably afford on a single salary.

    However, like I said, people don't want to compromise. They want to buy the biggest/nicest house they can. Same with cars. Same with holidays. Take my neighbours. They both go to work at about 7 and get home at about 7, at what point will they actually spend any time with those kids of theirs? They literally wake them up to ship them off with the grandparents and then put them to bed when they get home. What's the point in having kids if you're never going to see them? Do you think kids want to be shipped off all day to be raised by someone else?

    Anecdotally I've also found those kids that are raised by people other than their parents tend to be little sods, largely because people won't discipline someone else's child to the same extent that they'd discipline their own and the parents tend to feel that bad for not spending time with them that they spoil them. My sister is a prime example of this.
     
  12. Rroff

    Man of Honour

    Joined: Oct 13, 2006

    Posts: 61,157

    Easier said than done - increasingly you need two decent incomes to afford an appropriate house - you can't really go raising kids in a 1 bedroom flat or whatever and so on. Though there are always people who aim a lot higher than their means and/or don't want to make sensible compromises but that isn't a blanket story.
     
  13. Rilot

    Don

    Joined: Oct 18, 2002

    Posts: 19,268

    Location: Wargrave, UK

    In the 70s a teacher could easily afford a basic house on a 3x mortgage. That would equate to a property costing 60k today. Show me somewhere in the south east where I can buy a house for 60k. Or even a bedsit for that matter.
     
  14. Dis86

    Capodecina

    Joined: Dec 23, 2011

    Posts: 19,404

    Location: Northern England

    30k a year up here will comfortably net you a 3 bed detached.
     
  15. Dis86

    Capodecina

    Joined: Dec 23, 2011

    Posts: 19,404

    Location: Northern England

    There are other places outside of the SE...like I said, compromise.
     
  16. Rilot

    Don

    Joined: Oct 18, 2002

    Posts: 19,268

    Location: Wargrave, UK

    So, move away from all one's support structure, parents, friends etc? It's easier said than done if you work in an industry that is SE-centric.
     
  17. Rroff

    Man of Honour

    Joined: Oct 13, 2006

    Posts: 61,157

    For how long? it used to be far cheaper here in the SW than London/SE but last few years rapidly catching up and the notion that people can always just uproot and move across the country isn't well grounded in reality.
     
  18. Sheff

    Hitman

    Joined: Jun 16, 2008

    Posts: 905

    Location: Newton Abbot

    But now you've moved away from your family, meaning that you are no longer able to care for them.

    My family is scattered across the country; if my mum were to lose her husband and require care in 10-15 year's time then I'll likely be hundreds of miles away. Perhaps there could be some sort of care-swap scheme - I'll help look after an elderly person or someone in need of care here in Devon and someone else can do the same in Yorkshire.
     
  19. FortuitousFluke

    Mobster

    Joined: Jul 7, 2011

    Posts: 3,316

    Location: Cambridgeshire

    So it's been a few years since I looked at any of the papers but I'll try to give you a breakdown of Buurtzorg vs time and task models. At the moment the majority of Health and Social care systems in the UK will be looking after people across a range of disciplines (phys dis, Learning Dis, older people and mental health predominantly if we stick to looking at adult social care), these people will be in a range of settings but I'm mainly interested in people receiving care in their own home. For any individual receiving a package of care in their home they will have a number of "contacts", you might have a carer visiting say 3 x per day, a district nurse visiting x times per week, a GP who sees the person a few times a month, maybe a continence nurse or allied health practitioner who will pop in from time to time and then the social worker who usually has some responsibility for managing a portion of this and identifying needs. So let's say 3-6 "agencies" managing that person various needs.

    In terms of the health professionals who are involved, they're likely to be qualified to a certain level that allows them to complete complex tasks, this makes them expensive and rare in comparison to other disciplines so their time needs to be rationed and ringfenced for those tasks that nobody else can really deal with, they have more flexibility however to spend as much time as needed with a patient. Carers are still well trained but won't be qualified to do the level of tasks expected of a district nurse for instance, they will be working to a rota covering 8-10 service users and will likely spend 15-30 minutes per visit, there is very little scope to stay beyond that except in the case of an emergency. The social worker is responsible for identifying needs and allocating packages of care, they're good at what they do but there's unlikely to be much scope to step outside of the standard care package in terms of meeting peoples needs.

    So there you go, standard model at the moment, billing and allocation very much managed on a time and task (you have 15 minutes, you will complete these tasks in that time) model, multiple people going in to a service user, not much link up between agencies, not much in terms of thinking outside of the box (through necessity due to the pressure on the system), needs are being met but outcomes are much worse.

    Buurtzorg takes a group of professionals and allocates them responsibility for a "patch", they are required to meet all of the needs of the people in that patch but they have a lot more flexibility for how they manage that. The model is outcomes based rather than time and task which offers a level of flexibility. All of the need is funneled through one pipeline which means that the the locality team knows what all of the need is instead of health knowing about health stuff, social care knowing about social care stuff etc. That means that efficiency can be improved as you can potentially take what would have been 3 individual short visits from 3 different staff members across 3 agencies and provide a longer visit from just 1 person, evidence proves that better quality, longer visits improve outcomes, as does reducing the number of different people involved in delivering care. There's also less of an onus on the level of professional with everyone expected to deliver whatever task is required.

    Finally by reducing the number of contracts and taking a locality approach there is a better understanding between service user and professional, a closer relationship and a better knowledge of that persons desired outcomes. In addition the coordinators get to know what is available in the patch they work in allowing them to take advantage of things like social groups to help solve issues like social isolation.

    I should point out that when I was looking at the model it was only covering health, not social care, but you still get the same kind of benefits.

    In terms of prevention, if you look at care pathways as a ladder from low cost light touch approaches, up to high cost high intensity interventions then you're looking at something that looks a bit like this:

    Dom Care ----Residential Care----Nursing Care----Hospital Admission(this is a bit of an outlier as it's more of an event than a progression point)

    Now, prevention is concerned with slowing the speed of that progression as much as possible a) because it's cheaper to look after people at home and b) because the majority of people would rather be at home and c) because hospital admissions are ruinously expensive for the system. As well as avoiding crisis incidents that might lead to hospital stays or worse.

    Prevention would look at things like technology to support people, involving family and neighbours to do well being checks, identifying issues before people fall into crisis (e.g. somebody can no longer go upstairs due to frailty, adapt the house to allow them to live on the bottom floor, or somebody is presenting with the symptoms of a UTI, can we train carers to spot this when they visit before a hospital stay is required). Now the kicker is this, we all know instinctively that it's much cheaper to invest in prevention than it is to deal with the aftermath of a crisis event, however, it's almost impossible to prove because it relies on an event being prevented from happening in a circumstance where you can't say for certain it would have happened anyway. In addition they're always the first things to be cut when the Government slashes funding because they don't represent a statutory service.

    The LA I worked for hired a continence nurse to work with service users where there might be hidden continence issues. On the lower end of the outcome spectrum she would improve peoples QOL to the point where they likely stayed at home for longer before needing residential care. At the high end, is managing UTIs because people who suffer from UTIs become confused, dehydrated, more likely to fall, then they end up in hospital, where they will likely be catherterised and will lose independence, if they weren't incontinent before the catheter has a high chance of causing incontinence, and on discharge this person, who may have been managing very well on their own, now needs at least a hefty homecare package, possibly a residential home bed.

    Just one final point on the economics of this, when I was doing this as a job the average dom care package was maybe 10 hours per week with a single carer, total of about £160 a week. A residential care home placement was around £550 p/w and nursing probably £800 p/w, these could rise to £1200 depending on need. Our local Trust valued a bed day in a hospital ward lost due to a delayed discharge at £1000 per day. That should give you an idea of the pressure facing social care at the moment.

    Sorry for the no doubt indecipherable wall of text but there's a lot of experience to try and distill into a forum post!
     
  20. Dis86

    Capodecina

    Joined: Dec 23, 2011

    Posts: 19,404

    Location: Northern England

    Care is a need. Your son needs care. When you're an old wrinkly bugger and need care, it is a need.
    The other things you've mentioned are wants. This again goes back to that compromise I mentioned, you want to be around those people. You've prioritised being around them. I'm not saying I can't see the benefits and why you've made that choice but they're still choices.

    And many things are easier said than done. It doesn't mean they can't be done though. It's about making that tough choice to do them. I bet you could quit work tomorrow, move up here and spend every hour of every day with your son if you chose to. It wouldn't be easy. In the short term it might be utter hell. But I bet you could.
    As a note I have a friend who did just that. He quit a very well paid job and relied on just his wife's income as a nurse whilst he raised his 2 sons and daughter. They didn't live in a nice house. They didn't go on holiday. They drove a crap car. However he is literally the happiest man you'll ever meet as he got to spend every moment he wanted with those kids.
    One's still a nightmare like...