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Chapter 10: Funding issues
Different pots of money
A fundamental plank of our considerations is that the individual receiving a service should be at the heart of things, getting the services they need when they need them. When the person is at the centre, and services are organised around them, the organisation that provides the service becomes much less important.
While we have policies that promote integrated and partnership working there are, however, a range of funding streams that have created a financial infrastructure with different accountabilities that can run counter to the aims of these policies, and make it more difficult to join resources on the ground.
We believe we need to organise our view of policy and delivery around the individual receiving the service, and work back from that. So far as funding streams are concerned, the more they can be aligned so partnerships have flexibility and ability to use with the minimum of process, the better.
We can understand the desire to keep control of the very substantial amounts of funding provided for specific elements of the care and support system spent each year in Scotland. These include:
- resources allocated for NHS care;
- disability and other social security benefits;
- and the range of local authority funding streams for older people's services including
- free personal care
- care at home
- residential care
- direct payments and
- housing support.
In particular Ministers want to ensure that funding is spent appropriately and not diverted into other uses; this is often achieved through the use of separate ring-fenced funding streams with their own audit, monitoring and accountability arrangements.
We understand this desire to direct funding to ensure investment in the type of services the Scottish Executive wishes to promote. Nevertheless, we believe the reporting and accountability arrangements arising from these different funding streams can create practical difficulties in providing person-centred services and result in additional administration, adversely affecting overall value for money.
We recommend therefore that the Scottish Executive reviews the impact of different accountability arrangements surrounding the care and support of older people, and the scope to promote more flexibility and integration in the planning and funding of services for older people. We recognise the concerns though around the potential dispersion of funding into other services not related to the care of older people, and the considerable challenges in building safeguards around that, without separate accountability arrangements.
Value for money
We will always need to consider value for money across the health and social care systems and across statutory, voluntary and private sectors e.g. in care homes. The present arrangement whereby some relatively low dependency care in council residential homes can cost significantly more than that given to nursing homes for very dependent people remains to be resolved. There needs to be some incentive to maintain independence, but also a reflection of objective need. Choice cannot be unlimited and the public, politicians and professionals have to be engaged in prioritisation and establishing clear, transparent objective grounds for prioritisation. The limited public purse cannot support a growing number of expensive care packages if these are at the expense of basic care and support for many. This applies across all ages.
There is a difficult balance to be made when a care package to support someone in their own home costs more than to support the same person in a homely environment in their local community. If the emphasis is on supporting people to stay at home for as long as possible, there will be a cost attached to this. This is particularly so where the "at home" care is much more costly than in, say, very sheltered housing or a care home.
Local systems will always have to assess local needs and priorities, and review these regularly, and we believe this can facilitated within our conclusions.
Disinvestment in old buildings and services
There is considerable experience in Scotland of disinvestment in NHS continuing care and local authority care home services. There is benefit in reviewing what happened, for example in order to close NHS long-stay learning disability hospitals, so as to apply lessons to changing the balance of care for older people.
We felt that in Scotland good practice in disinvesting from out of date NHS or local authority buildings and institutional establishments to provide better care services in appropriate settings is not applied universally. There is a temptation to continue using existing buildings, and sometimes services too, simply because they are there. But needs and expectations move on, and there is a fundamental requirement to be radical about disinvestment in old buildings and services.
The ongoing move away from NHS continuing care accommodation towards more appropriate non- NHS models of care that better meet people's assessed needs is given added momentum by Building a Health Service Fit for the Future and by the Executive's response Delivering for Care. Further thought has to be given both within the NHS, and in partnership working with local authorities, to funding (including joint funding) for the whole of the balance of care provision for local communities.
It is expected that NHS Boards, and particularly, but not only, their constituent CHPs, will work closely together with their community planning partners, and in their Joint Future arrangements, to ensure that opportunities for innovation and collaboration are identified and taken to maximise alternative uses for NHS sites that become surplus to requirements, or to rationalise and/or dispose of such sites timeously. In this way they can secure the highest level of resources for their partnership(s) that will support and add impetus to real practical progress in delivering agreed alternative models of care.
It will be important to learn from, and act on, the lessons from traditional hospital retraction programmes and avoid, for example, ad hoc re-use of vacant premises outwith an agreed strategic approach.
Similarly, as some local authorities de-commission directly managed care home facilities, resources released should be identified to the local partnership for joint discussion and agreement about future commitments in line with agreed joint priorities, together with any other resources available to agencies within the partnership to support change
Partners should be able to display best value for the use of their collective resources in meeting the assessed needs of their population.
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