According to Haringey’s Design Framework for Integrated Health and Care, authorised by Beverley Tarka, Director of Adult Social Services, for presentation to the Council Cabinet on 13 June, Haringey’s approach has been ‘informed by evidence from the sector and from working with respected experts in the field, such as Professor John Bolton’. Who is John Bolton and what is his evidence?
A management consultant not an independent academic authority
John Bolton describes himself as ‘an independent consultant in social care’ with JRFB Ltd, a private company he established in 2011. He has long experience in social services management and policy development and he advises a number of local authorities on ‘efficiency and effectiveness’. He is an advisor to the Local Government Association’s Adult Social Care Efficiency Programme and also to the Economics of Social and Health Care Research Unit. Though he has no record of academic research, he has been appointed ‘visiting professor’ at Oxford Brookes University where he heads the Institute of Public Care (IPC).
The references provided by Haringey are entirely to research published by the IPC or the LGA. These papers have not been peer-reviewed for publication in an academic journal and cannot be regarded as what the Social Care Institute for Excellence characterises as ‘systematic research’. (Walden, 2015) Bolton’s work falls within the wider SCIE definition of evidence, which includes ‘organisational knowledge, practitioner knowledge and policy insights from regulators and policy makers’. It is best characterised as ‘advocacy research’: evidence presented in support of a policy that has already been established. The SCIE definition also includes ‘the views and experiences of people using services and their carers’. Though the Council refers to a number of ad hoc consultation exercises, neither Bolton nor Haringey have taken account of this sort of evidence in any systematic way. The only survey of the views of service users and carers in Haringey was undertaken by Mary Langan and Sarah Miller, members of the Learning Disability Partnership Board, and published in Learning Disability Today. (Langan, Miller, 2014)
Two phases of austerity
Bolton’s recommendations are based on surveys of adult social care in six English local authorities in the period between 2010 and 2015, corresponding to the Coalition Government and the first phase of austerity (following the previous decade of ‘efficiency savings’). He emphasises that these councils are ‘not representative’: they were chosen because they had made significant savings over this period (an average of around 20%), while ‘still operating a sustainable model of care’. (Bolton, February 2016: 14) This immediately raises questions of how transferable this experience is to other councils which may lack the enterprising leadership shown in these authorities and the skilled and experienced senior staff required to implement new approaches, especially given the onset of a second – even harsher – phase of austerity after 2015.
Bolton acknowledges that ‘the service is now under extreme pressure and facing financial crisis’ and repeatedly points out that even these authorities were anticipating great difficulty in maintaining services in face of further austerity cuts. (February 2016: 2) There is ‘minimal room to deliver further savings without major impact on what is offered or in meeting statutory obligations’. Again, ‘all of the six councils reported that they had little further room to deliver savings without having a major impact on what is offered, or in meeting their statutory obligations’ (February 2016:14)
Transactional and transformational
Bolton distinguishes between two approaches to making savings. (Bolton, February 2016:23) Under the ‘transactional’ approach, which accounted for the ‘vast majority’ of savings under the Coalition Government, councils tightened up eligibility criteria (limiting services to those with ‘critical and substantial needs’), increased charges, squeezed prices, closed down in-house provisions, cut staff and raised some funds from the NHS and housing partnerships. Though he believes that councils can still ‘divert’ many of those referred for adult social care by recommending assistive technology, or alternative ‘community’ resources, he acknowledges that the scope for further savings through these methods is now limited.
By contrast, Haringey has leapt upon Bolton’s claim, arising from case studies in four local authorities up to 2015, that ‘up to 75% of all adult care contacts’ can be diverted to ‘informal’ care arrangements by improving ‘front door’ systems. (Bolton, February 2016: 37) Adding referrals to ‘reablement and rehabilitation’ services could increase the ‘percentage of those not requiring longer term support to 90%’. Though it is not clear from Bolton’s account whether these figures are outcomes achieved in practice or simply targets, their relevance to many adult social care clients is questionable. For example, the vast majority of adults with severe learning disability do not arrive in adult social care through the ‘front door’, but through transition from children’s services.
Under the ‘transformational’ approach, the emphasis is on ‘managing demand’ by promoting ‘preventive interventions’ to encourage clients towards greater independence of formal care services. While this approach accounted for around 25% of the savings made by these councils in the period up to 2015, Bolton argues that in the ‘desperate’ situation facing local authorities as a result of the subsequent wave of austerity measures (confirmed in Haringey by the drastic three year programme of budget cuts agreed in February 2015), ‘transformation’ offers the only way forward.
Wishful thinking on preventing dementia
The main targets of the ‘transformative’ approach are the elderly (many with dementia) and younger adults with learning difficulties, the two groups which account for most of the demand on council resources. Though the demand for council-funded residential care for the elderly has slightly decreased in recent years, the burden of spending on those with learning disabilities has, despite all attempts to contain it, increased. This client group has proven the most intractable in terms of councils’ imperative to reduce costs. More clients are making the transition from children’s services (often with more complex needs) and adults with learning difficulties are living longer. Some adults have been transferred in recent years from residential homes to supported living schemes, often needing higher levels of support than the elderly, resulting in higher costs, sometimes higher than those of residential care.
Bolton claims that there is evidence that promoting healthy lifestyles can delay the onset of dementia and that ‘cognitive development programmes’ can delay its progress (though he does not cite evidence for such bold and contentious claims). At a 2014 seminar presentation at the London School of Economics, he indicated that his favoured source of scientific evidence in this area was newspapers. (Bolton, April 2014) He referred to a ‘promising’ new drug that was claimed, to a fanfare in the popular press, to delay the deterioration of Alzheimer’s disease – a promise that evaporated when the full trial results of Solanezumab became available in 2016. (Walsh, 2016) As is familiar in the world of public health, wishful thinking runs ahead of the science. Even if cognitive development methods are effective, it is difficult to see how they could be implemented if the day centres in which patients engage in these programmes are closed down and the specialist staff who provide them are made redundant.
More broadly, the LGA claims that its preventive approach is not designed to justify cuts, but is a reflection of its faith that ‘healthier lifestyles’ will curtail the demand for social care: ‘The approach is not about cutting services in response to financial pressures, but about pro-actively helping and encouraging people to live healthier lifestyles, thus reducing the need for formal social care’ (LGA, July 2014: 4) But where is the evidence that ‘healthy living’ can reduce the burdens of an ageing population or the prevalence of dementia, learning disabilities, autism and other complex conditions?
Reablement and recovery
In the drive to reduce spending on learning disability services, Bolton’s transformative approach incorporates a series of programmes that have been developed in the health care field. One is the reablement model, in which patients admitted to hospital with acute conditions (fractures, strokes) receive intensive physiotherapy and occupational therapy over a short period, with a view to restoring function and independence as rapidly as possible. An earlier paper published by Save Autism Services Haringey reported the view of the leading academic researcher in this field that this approach was inappropriate for adults with life-long neurodevelopmental problems. (Fitzpatrick, 2014)
Another model – ‘recovery’ – has been taken over from the sphere of mental health (where it was adapted from schemes for self-management of chronic medical conditions). This model seeks to encourage clients to understand and manage their own condition, while building a ‘support network’ to help them to avoid and deal with crises. Bolton acknowledges the limited application of this model in relation to mental health and a paucity of evidence, but claims ‘some solid anecdotes of this practice leading to lower costs and better outcomes’. (February 2016: 43) It is difficult to see how this approach could work with adults with severe learning disabilities and autism, given their level of cognitive impairments (remembering that only clients with ‘critical and substantial’ needs are eligible for council services).
A third approach, the ‘progression’ model emphasises the importance of developing care plans which focus on the potential for greater independence. Though he presents no evidence for his conviction, Bolton believes that even clients with the most severe disabilities can ‘do more for themselves’, enabling a focus on ‘outcomes’ to result in reduced cost. (Bolton, April 2016:44)
In the drive to cut costs, council-funded day care is ‘one of the biggest transformational challenges’. Bolton insists that ‘this is not solely about closing day centres but enabling and empowering people to move into different settings’.(Bolton, April 2016:18 ) Yet he immediately proceeds to recommend the practice of Nottinghamshire County Council which has closed two-thirds of its day centres since 2010. At the same time it has negotiated a five year contract with providers which assumes annual reductions in funding as ‘they help people to become more independent’. (Bolton, April 2016: 44) Bolton does not explain how Nottinghamshire’s providers are expected to foster greater independence at lower costs.
Bolton acknowledges in passing that day centres provide ‘stimulating’ support for clients and vital respite for carers – and are particularly popular among families of people with learning disabilities (Bolton, February 2016:26) Yet his major emphasis is that day centres can ‘institutionalise vulnerable people’ and foster dependence, thus justifying the drive to close them and pursue – unspecified – ‘alternatives’. Councils identify two major obstacles to day centre closures: providers and carers. From the perspective of councils keen to drive down costs, providers have a vested interest in maintaining established levels of provision and a conservative attitude towards the promotion of client independence. For Bolton, it is providers who ‘put this policy at most risk of failure’ (Bolton, February 2016:49)
Carers too are resistant to pressures to rationalise day services: according to the LGA they often ‘value the services that are in place’ and fear changes that will ‘put more pressure on them’. (LGA September 2016:14) In Darlington, for example, families were suspicious that council policy was driven more by ‘rationing and cost-cutting’ than a concern for the ‘enablement’ of family members. (LGA, September 2016:12) The LGA suggests that the family carer may also be resistant to measures to promote client independence and questions whether they are ‘the right person to act as advocate’. (LGA, September 2016:15)
Local government advisors recognise that confronting the challenges of driving through the service cuts required to meet budgetary targets will require ‘strong leadership and skilled practitioners’. (LGA, September 2016:26) For the LGA, the purpose of consultations and partnership and ‘co-design’ arrangements is to facilitate the rationalisation process. The key question facing the council is: ‘how can the carer be a helper in a way that their anxieties and concerns don’t prevent the service user from gaining independence?’ (LGA, September 2016:15).
The mantra of independence
The theme that recurs like a mantra through the reports of Bolton and the LGA is that of independence: all parties must have ‘aspirations for the service user to gain greater independence’ (LGA, September 2016: 15). But these authorities fail to recognise that individuals with high levels of disability can only achieve – and sustain – a degree of independence through the provision of consistent expert care and support. Whereas they assume that once a client achieves a greater degree of independence their support can be withdrawn and their care costs be reduced, this may not be practicable in many cases. Indeed, withdrawal of support may lead to a deterioration in function and even in mental health, resulting in increased longer term demands on health and care services. For example, Bolton indicates that a care plan may focus on identifying the circumstances that precipitate challenging behaviour so that support services can be reduced. (Bolton, April 2016:17 ) A recent small-scale preliminary study of ‘positive behavioural support’ (an approach ignored by Bolton) suggests that this approach may improve outcomes and reduce long-term costs, but this remains to be confirmed and, in any event, in the short-term many clients are likely to need continuing intervention. (Iemmi et al, 2015)
Furthermore, whereas Bolton assumes that all outcomes-focused care plans lead inexorably towards reduced levels of need and hence lower costs, some clients may experience temporary – or even prolonged – deteriorations in their condition and their level of functioning. This is most obviously true of older people suffering from dementia, but it may also be the case for adults with learning disabilities. For example, a young man with autism and learning disabilities may graduate from children’s services in which he was able, with support, to engage in a wide range of community activities. He may subsequently develop epilepsy, requiring closer care and supervision. He may resort to challenging and self-injurious behaviour, which both restricts his engagement in the community and presents particular challenges to adult social care services, in terms of both demands for professional expertise and for care arrangements. If quality of life is to be maintained – and long-term complications avoided – higher care costs are inevitable.
Cherry-picking in Saskatchewan
In his advocacy of policies which enable councils to justify cutting spending on adult social care, Bolton is keen to promote what he regards as ‘evidence’ of the dangers of any measures which may encourage people to seek care and support from local authorities. In his presentation at LSE, he cited ‘a Canadian study’ which he claimed ‘proved his point’ that ‘a little bit of care is bad for you’. (Bolton, 2014) Though in the subsequent Q&A he could not provide the source, it can be traced through a reference in his February 2016 paper. (HSURC, 2002) The study cited reported that ‘preventive home care’ for the elderly in the prairie province of Saskatchewan did not guarantee a longer life or a longer period of independent living. Indeed it suggested that elderly people who received ‘a light level of supportive care’ were 50% more likely to lose their independence and die earlier than those who did not receive this intervention. These results were reported in the context of a number of similar studies yielding equivocal or contradictory results, under the title ‘Conclusive evidence elusive for preventive home care’. Discussing this study together with a wider review of the literature, the authors concluded that ‘the evidence is equivocal in evaluating whether preventive home care achieves its goal of helping community-dwelling elders maintain their health and independence’. It is clear that the authors of this study did not believe that it proved the point claimed by Bolton. It is doubtful anyway whether a study of the care of the elderly in rural Canada can be generalised to be applied to that of people with severe learning disabilities in Haringey.
Bolton, J. (April 2014), Policy, practice and austerity, London School of Economics Health and Social Care, formal seminar;
Bolton, J. (April 2015), Emerging practice in outcomes-based commissioning for social care, Discussion Paper, IPC/Oxford Brookes.
Bolton, J. (February 2016), What are the opportunities and threats for further savings in adult social care?, IPC/Oxford Brookes.
Bolton, J. (April 2016), Predicting and managing demand in social care, Discussion Paper, IPC/Oxford Brookes.
Fitzpatrick, M. (2014) Realities of reablement, Save Autism Services Haringey (December): http://saveautismservicesharingey.co.uk/wp-content/uploads/2015/01/Realities-of-Reablement.pdf
Health Services Utilisation and Research Commission (2002), Conclusive evidence elusive for preventive care, Background Paper No5, HSURC: Saskatoon, Canada (March).
Iemmi V, Knapp M, Saville M, McWade P, Toogood S (2015) Positive behavioural support for adults with intellectual disabilities and behaviour that challenges: an initial exploration of the economic case, International Journal of Positive Behavioural Support, 5, 1, 16-25.
Langan, M., Miller, S (2014) Impact of cuts in services for people with learning disabilities in an inner city borough, Learning Disability Today (November/December).
Local Government Association (2014), Adult Social Care Efficiency Programme: The Final Report, LGA (July).
Local Government Association (2016), Learning Disability services efficiency project, LGA (September).
Walden, D (2015), Introduction, Re-imagining Adult Social Care: Evidence Review, Dartington: Research in Practice for Adults: www.ripfa.org.uk
Walsh, F (2016) Hopes for new Alzheimer’s drug dashed, BBC website, 23 November: http://www.bbc.co.uk/news/health-38080132