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The politics of funding – the conflicts of interest for those charged with transforming care

On Tuesday 13 September at 8pm, our Chief Executive, Steve Scown, was on Radio 4 discussing Transforming Care. In this blog he discusses conflicts of interest for those leading the programme.

By Steve Scown, Dimensions CEO
Dimensions CEO, Steve Scown, blogs

Rachel* has had a difficult life. Profoundly deaf, and with very little sight, her mother was ill with Rubella whilst pregnant.

Until recently she has been stuck in a health-run ATU, with costs paid for by health, under the responsibility of her local Sensory team. But recently her diagnosis changed, from developmental delay to learning disability. This enabled her to access different funding and she was referred to Dimensions.

Without any doubt in my mind this nimble footwork helped get Rachel out and she is really thriving with our support. Her story got me thinking again about the politics of funding, and how this can both positively and negatively impact on people’s lives.

If you listen to File on Four on Radio 4 you’ll hear how Transforming Care has missed its trial target. NHS England has admitted community services aren’t good enough, and could risk the £130m programme not achieving its ambitions.

Rachel’s life is certainly better now. But what about fictional John?

John has a learning disability and lives with his parents, who support him. He’s going through a rough time and his parents ask the local authority for help.

What John and his family really need is flexible, responsive, local, expert support. But this support isn’t there, his situation at home deteriorates and John is referred to an Assessment and Treatment Unit (ATU.) Not because he has a health need that needs treatment but because the right support wasn’t available in the community. A place at the ATU is. Now, John’s support is funded in whole or in part by Health.

Or consider similarly fictional Peter. Peter has been living in an ATU for two years, but there’s no longer any reason for him to stay locked up. He could be supported to live in the community – he’s desperate to get out and have a life.

Everyone who is important in Peter’s life knows this and wants this to happen. In three more years, the Health dowry will kick in (why five years? Dimensions, along with others, has previously proposed a reduction from five to two) and health funding will be added to Peter’s funding pot.

If Peter leaves the ATU now, his local authority will have to pick up the whole cost of his support, and his current provider will have an empty bed. Do you think that if the money to fund Peter’s services was controlled by his family, or an organisation acting on his/their behalf, that he would be in a minute longer than necessary? We could always call that a personal budget…

Too cynical? Put yourself in the shoes of an under-funded social care commissioner faced with balancing impossible demands on budget and service provision. In the cases of both Peter and John, there’s no chance of their funding being redirected to community based preventative support – it is necessarily committed to sustaining current services and packages.

I believe that short term investment funding – sustaining existing whilst investing in preventative community-based services is required. We know community-based services are not only better in terms of quality of life and outcomes, they are cheaper as well.

Jon exercising
Community based services can improve quality of life

My cynicism is backed up by the data. 64% of inpatients have been in the same hospital for a year or more – hardly “assessment and treatment.” And this understates reality, as it ignores transfers.

Of new admissions to hospital in July 2016, just 15% had a pre-admission Care and Treatment Review (which would oblige a discharge plan to be put in place.) Of the 85% who did not receive a pre-admission CTR, 85% had also not had a post-admission CTR at time of data collection (A CTR should be completed within 10 days following admission).

Looking more broadly, at all inpatients, just half had a CTR within the allotted six month timescale; fully 28% had not had one in the preceding year. And the position is getting worse; a year previously, 77% had had a review in the allotted timescale.

The HSCIC data also reveals that 70% of inpatients’ care plans say they need inpatient care; 30% do not. This figure is virtually unchanged from six months previously – so why are the 30% not getting out?

There’s an acid test to evaluate efforts to transform care. It is this: Are commercial providers of ATUs investing, or exiting the market?

The answer, I’m afraid, is that the major private players are investing in their facilities. They see more demand and more opportunity, not less. And overseas investors see opportunity too – witness Acadia Healthcare’s purchase of Priory Group for £1.5bn in January this year.

In the politics of funding, there remain many incentives for providers and commissioners not to push to get people out. The danger is that if we don’t really invest in developing community alternatives whilst also funding current bed stock, people will move from NHS beds to non-NHS beds in so-called ‘rehabilitation’ and secure units, a pattern we have seen in mental health.

My grandma used to say that if it looks like a duck, and quacks like a duck, it is a duck. Well this looks like, and sounds like, funding politics keeping people locked up.