The LGA perspective

This article forms part of the LGA think piece series 'Towards a sustainable adult social care and support system'.

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Sending the right message from the centre

The addition of ‘And Social Care’ to the Department of Health’s title is important recognition that adult social care is vital to supporting people’s health and wellbeing. Whether it points to a more meaningful shift in the Government’s core messaging around social care remains to be seen, although examples of presentation and practice do not give cause for immediate hope.

In presentational terms take, for instance, the department’s single departmental plan. This includes no mention of ‘adult social care’ as a stand-alone objective and the service is instead captured mostly under the objective of transforming ‘out of hospital care’. An isolated observation such as this is not a cause for concern. But the accumulation of similar presentational issues adds up, creating a clear – and unhelpful – sense that national, rather than local inputs are key to supporting wellbeing. And of course, there are practical concerns as well, the treatment of the £2 billion for adult social care announced in the 2017 Spring Budget being a case in point.

Described in the Budget book as, “additional funding for social care to councils…to help ensure people receive the social care support they need and to reduce pressure on the NHS” this £2 billion has become a central part of the Government’s response to continued questions about the sustainability of the sector in the short-term with its focus on three priorities: meeting social care needs, reducing pressure on the NHS, including supporting people to be discharged from hospital when they are ready, and ensuring that the provider market is supported.

However, just four months after the Budget, the second of these priorities came clearly to the fore with an announcement that councils would be expected to reduce social care attributable delayed transfers of care (DTOC). This is a joint target with the NHS, with each side bearing 50 per cent of the responsibility despite the split of NHS and social care attributable DTOC being far from 50-50. Furthermore, it was announced that areas faced the possibility of a review of their allocation of the £2 billion in 2018/19 if they performed poorly against the target.

It is difficult not to read into this that the Government sees social care as a local service which should prioritise its ability to help reduced demand pressures on the NHS nationally. And it is no exaggeration to say that the increasing national influence and narrowing of focus associated with this money – despite social care comfortably outperforming the NHS on DTOC reductions since targets were set in July– has undermined local leadership of integration in many areas.

With the above in mind, and looking ahead to the green paper, Government must send a clear message about the importance of adult social care in its own right and embed greater parity between the contribution of ‘local’ and ‘national’ in supporting people’s wellbeing. Only in this way can we help secure the right “blend” of national and local, as Glen Garrod advocates below.

Democratic accountability

One way in which the Government could help secure a healthier balance between ‘national and local’ is through Sustainability and Transformation Partnerships (STPs). The LGA supports the intentions of STPs to develop place-based partnerships to implement plans to improve health and wellbeing outcomes, improve quality and safety and ensure the financial sustainability of local health and care systems.



However, in practice STPs have been dominated by the financial challenges faced by the acute health sector. In most areas there has been little attempt to engage councillors in a meaningful way in the development of STPs and, as a consequence, most councillors have little confidence that STPs will achieve their objectives.



This matters because councillors – be they leader, lead member or backbench member – have a key role to play in embedding democratic accountability into health and social care, as Cllr Colin Noble notes below. Lead members of adult services are particularly important pillars of the health and social care community. They ensure their councillor colleagues understand the scope and importance of the wellbeing agenda and through their regular cabinet meetings and health and wellbeing board meetings help ensure that all relevant council services link in to the wellbeing process. Similarly, their discussions with frontline councillor colleagues ensures that awareness of the wellbeing debate is raised amongst residents.  This helps further embed local democracy and a local understanding of how decisions on adult care services are made. 



This is important because, as recent LGA polling on resident satisfaction shows, councils are the most trusted form of government to make local decisions about services in a local area, selected by 71 per cent of respondents. Just 15 per cent of respondents selected national government. And again, in terms of individual politicians, local councillors were selected by 69 per cent of respondents as individuals most trusted to make decisions about local services. By comparison, 13 per cent of respondents selected Members of Parliament, and just 7 per cent selected government Ministers. This further underlines the point that the local dimension of social care matters because it provides clear democratic accountability that strengthens the ties between those requiring care and support and the council – and its many local partners – that ensure the availability of quality services to meet needs.

Managing resources

Nobody should underestimate the challenging work that councils have done since 2010 to manage major reductions to their core funding from Government. The LGA estimates that reduction will total £16 billion between 2010 and 2020. That a number of key measures in the LGA’s polling on resident satisfaction have stayed broadly constant or improved since 2012 when the polling began is testament to councils’ work (for instance ‘satisfaction with the local area’ and ‘trust in council’).

During this time, councils have sought to prioritise and protect adult social care. The ADASS budget survey shows that adult social care accounts for a growing total of councils’ total budgets, increasing from 35.6 per cent in 2016/17 to 36.9 per cent in 2017/18. However, given this proportion, it has been impossible for adult social care to be immune from having to make its own significant contribution to councils’ overall savings. For this reason, savings and service reductions have been a key factor in managing a £6 billion funding gap that adult social has faced since 2010. But again, some key performance measures have been maintained or have improved, such as: the proportion of older people still at home 91 days after discharge from hospital into reablement/rehabilitation; overall satisfaction of people who use services; and the proportion of people who use services who feel safe.

The financial environment councils have had to operate in contrasts markedly to that experienced by the NHS. While local government will have managed reductions to its core funding of £16 billion between 2010 and 2020, we estimate that NHS spending will have increased by just over £20 billion over the same period, from £95.2 billion in 2010/11 to £114.8 billion in 2019/20. Funding for health has increased at the same time as providers continue to report significant deficits. Latest performance information from NHS Improvement shows that providers forecast an aggregate full year deficit of £623 million, which is £127 million worse than planned.

Trying to compare approaches to budget management between health and social care is difficult given the operational differences between each side. For example, trusts can set deficit budgets whereas local authorities are required by law to set a balanced budget. But without question, councils have proved more than capable of making tough decisions, innovating, and driving efficiencies, far beyond the experience of most parts of the health service.

Locally tailored care and support

Council areas are unique with no two the same, even at a regional or sub-regional level.  Some big cities may have high levels of deprivation and a high number of residents with chronic long term conditions, whilst other more rural areas may be relatively prosperous but have a high number of retired people. In some parts of the country, services relevant to the adult social care agenda are provided by both county councils and district councils.  Freedom and discretion to make local decisions on adult care is therefore crucial. 



The local knowledge at the heart of such decision-making is key to the delivery of adult social care, with its emphasis on achieving outcomes for individuals, their families and communities.  This is a critical point because as we continue pursuing a more personalised approach to care and support, it is likely that the local offer may become more bespoke, and will cross the boundaries of care, health, public health, housing and a range of other local services.  This local offer of bespoke services developing within and between agencies will also include the delicate balance of people’s own resources, community support and the invaluable input of informal carers.  An interlinked care and support system spanning the public, private and independent sectors and geared towards prevention, wellbeing, and choice and control cannot operate successfully if disturbed by attempts to run it at a national level.

Furthermore, the idea that a more national system would help eradicate unwanted local variation is flawed. One need only look at the availability of cancer drugs, dental and IVF treatments, and the huge variation in eligibility for Continuing Healthcare, as evidence that national systems do not always yield a standardised offer.