A thought on Council budgets and social services...

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Councils spend a lot of money - £1.3 billion in Bradford's case - but the bit that matters is the "net revenue budget". This is the bit that remains after we take account of fees and charges, remove money that is simply passed through the books (e.g. the money that goes to schools) and adjust for things we do on behalf of government like pay benefits.

In Bradford this figure is £425.9 million of which 38% comes from the Council Tax with the remainder (bar around £6 million taken from reserves) coming from central government grants. Between friends we can call this a 40/60 split. And, assuming the finance director's guesses are more-or-less right, future reductions in grant will mean that this split will be approaching 50/50.

Which brings an interesting observation - the Council's spending on what we used to call social services (children's services and adult social care) is now some £203.3 million. This is around 48% of the net revenue budget. In simple terms, the grants we receive from government pay for social services.

All this rather begs a question - since there is a national debate around adult care and a move from council commissioned block grants to personalised, individual purchase, there is little justification for this being seen as a necessary council service. The private and voluntary sector are more than capable - as is the case with housing - of making this provision. Local government is superfluous except perhaps as a quality regulator (much better and fairer when the council is not also a major provider).

Children's services remain a problem but, given the nature of these services and the limited scope for any meaningful councillor input, there is perhaps an argument - I would need convincing - for child protection and services to be run by a government agency. Service provision - children's homes, adoption and fostering services and so forth - could be commissioned (perhaps from the big children's charities).

If this were the case then nearly 100% of Bradford Council's funding would be raised locally.

It's thought...


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Public health and private choice - thoughts on a consultation

This afternoon I attended a Public Health Consultation event organised (because I insisted) to allow Bradford councillors to have some input into the PCT/Council response to the Public Health White Paper. Obviously our input was constrained by time but we managed to comment at length on:

Domains and Indicators from Healthy Lives, Healthy People: Transparency in Outcomes: Proposals for a Public Health Outcomes Framework

And:

Commissioning and funding from Healthy Lives Healthy People: Consultation on the funding and commissioning routes for public health

In this discussion we looked at the different “measures” that might be applied to the assessment of public health effectiveness and hence the likelihood of Bradford Council receiving the “Health Premium” promised to Councils meeting targets. In listening to this – and looking at the targets – it struck me that there is an interesting and important discussion to be had as to what we actually mean by the term “public health”.

What seems clear to me is that the domain of public health – our concern to do something about external and environmental factors contributing to disease and ill-health – has expanded to encompass things that are not external to individual choice. Hence the ‘new’ definition from the Faculty of Public Health:

“The science and art of promoting and protecting health and well-being, preventing ill health and prolonging life through the organised efforts of society.”

Public health is no longer concerned with externalities – with sanitation, with poor housing, with air pollution, with clean water – but with lifestyle choices deemed by “society” to be wrong. And the justification for this action is all couched in generic health outcomes, chiefly in “life expectancy” and “healthy life expectancy”.  Because, for example, reducing smoking is seen as improving overall “life expectancy” it becomes justified even though such interventions are not in areas of ‘public goods’.

Underlying this argument is the nature of the deal between the individual and the state – whether that deal in a collective or individual arrangement, between the ‘civic’ and the ‘personal’. And, most commonly, the argument is couched in terms of selfishness – my drinking, smoking or fatness means a greater burden on the NHS and less resource available to treat the illnesses of good people who eschew such a decadent lifestyle.

If however – as I believe is the case – my relationship with the state is a personal one, then this argument is false. I pay taxes, duties and other imposts in return for the state’s protection. And that protection applies to me personally not to me as part of a collective. My lifestyle choices – smoking, drinking, eating burgers, sky-diving, potholing, and so forth – are not a matter of public concern. Therefore public health cannot – as its proponents now argue – extend to controlling lifestyle choices but must be limited to public goods and to the impact of public services on health.

Nevertheless, the consultation paper on “proposed indicators” contains nine targets directly linked to levels of smoking, drinking or eating yet just two relating directly to housing. Yet housing conditions – damp, drafts, poor heating – are very significant factors in ill-health, arguably more significant that smoking, drinking or obesity. Add to this the incidence of ill-health linked to long-term unemployment and poverty and it is clear to me that the directing of around 60% of public health budgets to booze, fags and burgers is wholly misplaced – even if we accept the argument that there is a need to develop responses to these “problems”.

In the end, the experts – those nannying fussbuckets of the Faculty of Public Health – will win the day and the funding will go to continue the current strategy. And this is despite all the evidence that this strategy is failing to deal with the problem it intends to deal with (too much drinking, smoking and burger-eating). At the meeting I pointed out that reports of liver disease had risen during a time when the consumption of alcohol was falling – the answer to this conundrum is that the problem drinkers are drinking more ergo more liver disease!  I’m not sure that I believe this – the problem may relate more to the increase in drinking during the 1980s and the lag in presentation for liver conditions.

While I enjoyed the meeting and made a substantial and, hopefully, substantive contribution, I expect that we will end up with a centrally directed, nannying (or should I say nudging) approach focused – to the exclusion of almost everything else – on the poor lifestyle choices that some people make. And it won’t work – the single mum on the sixth floor of a council block will still want cheap stimuli, the little cheers and buzzes that get her through an otherwise crap life. Which means she’ll carry on smoking, drinking, enjoying sex, eating crisps or chocolate and watching telly – those things are her pleasures and telling her it’s bad for her won’t change a thing.

 If you want to change her outlook – or the outlook of a million or so other folk – you have to change economic prospects, improve the housing and clean up the locality. And all the public health fussbucketry won’t achieve any of that, will it?

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Death doesn't become us - a thought on mercy killing

Anna Raccoon, in that knocked-back, slightly laconic manner she takes, describes yet another travesty of life sourced from the Court of Protection – the tale of Wally which she concludes with:

He was a success story by Court of Protection standards too. Probate had been obtained, building society funds duly accredited, house put up for sale to fund his care home, Statutory Will made out, Receiver changed to local solicitor.  Not much left in the account after all the legal bills had been paid.

I drove past the houses on my way to the next appointment. All one colour now, the second front door blocked up – I dare say the courtyard had been gentrified too. I could guess who’d bought it.

Everybody patting themselves on the back – job well done.

And, like these things do, it reminded me of the stories my Mum used to tell – of rapacious relatives, incompetent and venal solicitors and idle carers. Above all, Anna’s tale reminded me of my Mum’s argument against “mercy killing”.

My Mum spent 25 years and more working with old people in and around Penge – delivering meals-on-wheels, driving the mini-buses and running Penge & Anerley Age Concern’s lunch club and day centre on Melvin Road. In this time she saw every sort of folk – from Mr Squirrel who worried that he couldn’t (at 96) dig the garden as in times past to Dr Arnott, communist party member, academic historian and employer of a maid.

Every day, my Mum would tell us, one or more of the people she saw would proclaim – in that depression of loneliness so common among the old and infirm – “I’m just a burden, I’d be better off dead”, or some similar formula of despair. Mum’s response would be to tell them not to be so silly, have a cup of tea and a chat.

But Mum’s view – informed by bitter experience – was that not all the relatives and carers took the same view as she did. And, Anna’s tale of Wally reminds us of this:

The local Doctor was persuaded to sign a form for the Court of Protection – Wally ‘wasn’t taking care of himself’, ‘had no appreciation of the need to pay his council tax’ – Mrs Wally had been paying for both sides of the house for years, unwilling to let Wally’s negligence lose her a desirable home – it was sufficient. ‘Mrs Wally’ was duly installed as Receiver, and everyone assumed that she was his Mother.

All Mrs Wally did was to arrange to part Wally from his property and cash – imagine a world where that form is placed before Wally and his sort? The one where a depressed, slightly confused, sad old person signs to say they want to die, where the bureaucracy takes this as consent and Auntie Sissie or Grandpa Geoff is shipped safely across the Styx leaving his worldly goods behind for the inheritors to enjoy.

It is a depressing truth that much of the debate about our treatment of the old is informed less by understanding or sympathy than by totting up the banknotes tied up in these people’s homes and chattels. Banknotes that could make some old persons last few years more comfortable but which we leave there instead for the relatives to scrap over after they’ve died. And it’s a further depressing truth that “liberalising” euthanasia would grant the opportunity to bring forward the time for that division of spoils – all it will take is a consent form.

Anna’s tale of Wally reminds me why mercy killing – for all that it’s wrapped up in soft words and informed by tragedy – remains killing. And we shouldn’t make that easier, should we?

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What were they thinking? Of course prisoners shouldn't get the vote.

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My decidedly liberal attitude to criminal justice faced a challenge as the great "should prisoners get the vote" debate raged. And yes, the quite hideous John Hirst did a pretty good hatchet job on my willingness to support liberalisation but that wasn't the clincher. The clincher is this blogpost from SadButMadlad on Anna Raccoon's site where he suggests we treat prisoners in the same manner as many of our elderly, nursing home 'customers':

The criminals would get cold food, be left all alone and unsupervised. Lights off at 8pm, and showers once a week.  Live in a tiny room and pay £600.00 per week and have no hope of ever getting out.

Now I know not all old folks homes are like this - especially the creative, modern ones in the private sector - but it's a strong point. And bear in mind that plenty of those old people are effectively denied the vote too since no-one bothers to make it possible for them.

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Here's a dilemma....

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...perhaps not too tricky a dilemma for some but interesting nonetheless.

Bradford Council (pdf) run 11 residential homes for the elderly in which live around 300 people supported by a significant number of council employees. It might be helpful for you to know that the cost per resident, per week in Council-run homes is roughly 50% greater that the cost for the same service in the private and voluntary sector. The Council is consulting on closing some of these homes, keeping some and building new ones as part of a major reconfiguration of the service. This is based on assumptions that a capital strategy to fund this development programme can be constructed. The driver for the strategy isn't "cuts" but a realisation that the Council service does not begin to meet the expected needs of future users.

However, the Council's Adult Social Care Directorate has been asked to consider how up to £27million in savings might be delivered within the overall service (this is a 25% reduction). The aim has - I'm sure you will agree - got to be to maintain current services which include residential care, domiciliary support (what we used to call 'home helps') and a range of day care and other support to vulnerable adults. One option in all this is to adjust the basis on which service and support is provided - rather than providing free care to those elderly people with 'moderate' or greater needs we could limit such provision to those with 'substantial' or higher needs.

Now the direct saving from shutting the homes and buying places in the private sector is £3.6million. This figure is slightly higher than the savings we might realise from changing what are know as 'Fair Access to Care Services' (FACS) criteria (somewhere between £2m and £3m) all this can only be an estimate subject to detailed appriasal and possible legal challenge. The result of changing such criteria is that some people who receive a given service from the Council will no longer receive that service.

It seems to me that in this dilemma lies one of the great lies we hear from the left - and indeed from the unions representing public employees. Closing eleven council old folks' homes will not result in any loss of service - the residents will be housing and cared for to the same standards as before - but will result in the redundancy of the council staff working in those homes. Changing the FACS criteria will not result in any loss of Council employment (most of the services are delivered within the private or voluntary sectors) but will result in a reduction in service to vulnerable adults.

This is a simplified version - the full picture is more complicated - but it indicates the sort of decision being made by local councils across the country. And remember that (while those councils are not wholly innocent) Councillors making the decisions are doing so within the funding available. What I wonder is how many Councillors would opt for closing homes and face the unions' opprobrium and how many would take the savings elsewhere - and actually reduce service to the public - rather than make those care home employees redundant?

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“We’ll give you one of those clicky things…"

…..and you can vote on what you like or don’t like”

So spoke a Council leader when asked about choices, Big Society and the delivery of services by anyone other than the local authority. This, we’re told, is ‘participation’ – you’ll be consulted once we’ve decided what we’re going to consult you about. You’ll be herded into making forced choices with a ‘clicky thing’ but what is important is that everything is ‘coherent’ and ‘co-ordinated’. Which of course is your council’s role.

On another day at a different council, a leading local councillor – having said that Big Society makes her sick, then tells the assembled supplicants that the council will decide on the basis of ‘consultation with the sector’. No innovation, no creativity – above all no untidiness.

I could cite other examples – dozens of them – as local councils thrash about following the Spending Review. And in every case there is an absolute desire to keep control. To dictate, to order things, to plan, to strategise. While there are examples of councils making radical decisions about services they are the exception.

Yesterday, I was looking at the impact of “the personalisation agenda” on the delivery of local authority – and voluntary sector – services to the elderly and disabled. And it struck me that this agenda – introduced by the last Government – should represent a substantial and significant shift in the way we deliver these services.

Or rather that we (by which I mean local councils) should stop “delivering services to vulnerable adults” and instead start acting as the carer of last resort. The point of personalisation – and I guess the point of the Big Society – isn’t to give people a clicky thing but to give people the power to decide who they get services from rather than have someone else do that for them.

And we don’t need tidiness to make this work. We just need to allow the people who actually make and deliver the services for ‘vulnerable adults’ to sell their services to those – hopefully more empowered and less vulnerable as a result – adults. By all means quality assure. Certainly take on the role of carer where people don’t have others to do this. But stop second-guessing what people want.

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