To solve the crisis in care for older people, think health, not ill health

http://www.theguardian.com/society/2015/sep/01/elder-care-crisis-local-heath-social

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Few doubt that we are facing a crisis in the care of older people. Most of us are living longer and will have more complex health, social and mobility needs. The Care Act raises expectations of solutions, yet the government’s promised £8bn investment in the NHS soaks up any additional resource in the system and, indeed, raises the pressure on social care through greater clinical activity.

Related: The scandal of 70,000 older people who aren’t getting the support they need

Funding for social care remains in the unprotected area of local government that faces further cuts on top of the major reductions of the past five years. There is simply not enough cash in the system to fund existing services, let alone meet the demands of the new “national living wage” or invest in growth.

While there may be a consensus about this analysis, it is less well appreciated that some of the solutions posed are likely to make the situation even worse. That is why the Dunhill Medical Trust, of which I am a trustee, is setting aside £1m to test a bottom-up, community-based approach to social care for older people. Most proposed solutions are based on adapting existing systems, such as integration of health and social care. Yet these systems are fundamentally different. The NHS is free at the point of need, directed nationally, inexperienced in dealing with independent providers, institutionally inefficient and characterised by very strong professional cultures.

Many people fund social care themselves. For the majority, public support is based on strict assessments of need and individual financial contributions, administered and commissioned by local councils and provided, in the main, by charitable and private providers under contract. Local government is arguably the most efficient part of the public sector, but financial restrictions have reduced service availability and squeezed prices.

The long-term answer to this care crisis is surely to concentrate on health, rather than ill-health and disease

Laudable demands for higher standards, such as better staffing ratios and more time spent with service users, better leadership, systematic training and development and payment of the living wage for care staff, create an unbridgeable gulf with a financial commissioning imperative to freeze or even reduce contract fees. Most providers practise open accounting, showing that the system is truly in crisis, with many suppliers struggling or leaving the sector.

The long-term answer to this care crisis is surely to concentrate on health, rather than ill-health and disease, with medical and social care delivered in people’s own homes, residential centres and other community settings. In the medium term, this will save significant hospital costs because people will seek inpatient treatment only for specific clinical procedures, with after-care in the community.

This provides the policy context for what should be happening while this new focus is created. In contrast to NHS England’s “vanguard” pilots, which reconfigure existing systems in pursuit of new models of care, successful approaches are not about health and social care alone, but aim to release all local resources to provide better accommodation, transport and initiatives to combat physical and social isolation – whether provided by public or private sectors, local groups or still more informal arrangements.

Local councils should use their community leadership responsibilities to enable this whole-systems approach to flourish. Planners, commissioners and corporate and informal providers of care and support would all operate as active partners in finding and sustaining solutions. There need be separation only for formal decisions, such as the awarding of contracts. All financial resources – including the benefits system, the NHS, local government and individuals’ own resources - should be pooled and focused on wellbeing.

In this approach, people and their needs are at the centre of activity, rather than fettered by organisational cultures and imperatives. This is the real meaning of wellbeing enshrined in the Care Act. It turns our assumptions and traditions upside down by enabling everything to be directed at community support as the context for meeting individual need. It could dispense once and for all with turgid arguments about whether service responses come from the public or private sector.

But we need evidence of the potential of a local approach to meet the requirements of increased numbers of older people in an age of finite resources. The Dunhill Medical Trust intends to fund a practical application. Further details will follow this autumn.