James Bullion, Executive Director of Social Services at Norfolk County Council is the man charged with overseeing the delivery of social care and support for tens of thousands of people in the county. After spending most of his career in Norfolk, he worked in Essex before returning to lead the service following the death of Harold Bodmer.
But who is he and what are his ambitions for the service? Shaun Lowthorpe spoke to him about his plans.
The Cost of Care
At £252 million pounds, the budget for vulnerable older people in Norfolk is a huge chunk of the £389 million pot the county council plans to spend on services in the next financial year.
They’re big numbers, but actually they don’t cover the costs of meeting the demand from the growing number of people who need the services, and worse they are going to be cut further still, which means you may find some social care services you or your family rely on either being scrapped or left with you picking up the tab, if you can afford it, that is.
James Bullion, the man tasked with juggling that balancing act, has been heading up social services since returning to Norfolk from Essex to take up the role in November 2016.
Living Well Programme
He is placing his faith in a programme called Living Well, which he hopes will see social workers ‘sticking to people like glue’; and also by pursuing closer working with the NHS.
That second strand is nothing new and is akin to the Holy Grail for policymakers at all levels. Yet overcoming the silo working and different cultures between health and social care has never been easy.
However, buoyed with an extra £40m to focus on ‘preventative services’ maybe he will enjoy better luck?
“If I start at the top with the strategic challenge, the big challenge is sustainability of firstly the budget but secondly just getting access to care services,” he says.
“We have this challenge of growing demand and a sustainable budget to meet. In Norfolk, even when you take the Council tax rise and the precept rise that we’re given permission to do by government, and even when you add more in for demographic growth, you’re still in a position where you’ve got to change the nature of the way you’re working with people to try and get that sustainability question answered.”
“So, the strategy here is to raise enough money through that system of taxation and grants from government. And it’s to attract the NHS in to working with us in the council to take a preventative approach.”
But others are not convinced that those good intentions have yet translated to meaningful change on the ground.
Why health and social care need to speak the same language
Alex Stewart, CEO of Norfolk Healthwatch, for example, is not so sure.
“There is still this different language being spoken between health and social care – it’s like never the twain shall meet,” he says. “All the efforts to integrate are really laudable but, unfortunately, I think we still have a long way to go.”
He believes that part of the problem is a misplaced fear among staff running scared of falling foul of the Data Protection Act.
“They can talk to each other,” he says. “I think people are afraid to do so – whether it’s social care and housing or a third sector organisation such as the CAB.”
“We need to train staff in how to interpret the Data Protection Act more effectively.
“If you are looking after an individual or a family – the needs are what comes first and you should be able to share information.”
Integration & Optimism
However, James Bullion remains optimistic that progress can be made.
“There is a business case for the NHS working with us because we can prevent, reduce, delay need and that then impacts on them,” he says.
“I want us to be really strong partners to integration. Part of the reason for doing it is that doctors see people before they come to us. They only come to us quite late in the process often when they are in crisis. Whereas if we can get our social workers and our staff into a GP situation then we can see people earlier and the interventions don’t necessarily have to be expensive, formal services.”
“Also, we don’t habitually swap information between the NHS and local authorities. We do on an individual case level but on a population level we don’t.”
“I reckon that doctors have got the potential to see people probably 18 months before they come to us.”
But you wonder if part of the problem is that thanks to years of reorganisation and cost cutting that we’ve taken out a whole tier of support which would have been the old community hospitals?
“I think rather than have gone, the resources have changed radically,” he says. “So, they are there but they are used for a different purpose.”
So, isn’t the answer to go the whole hog and have a national care service merging the NHS with Social Care, as some most notably the Labour Party have suggested?
“Ultimately that is a political decision and there are different views around that, partly because of the means test question,” he says. “Health is free at the point of delivery and social care isn’t and has never been free, despite a popular common myth that it’s free. It’s always been means tested. And I think there’s an unresolved question about that.
If you’ve got someone with dementia say, sometimes the NHS are providing that care free for the person because their primary need is a health one, sometimes social services are providing the care because the primary need is a social one because they don’t have an associated medical condition.”
Part of his plan with Living Well is to trial a new way of delivering social care services in seven pilot areas across Norfolk, with an emphasis on prevention and avoiding crisis situations.
“People get in touch with the social worker and that social worker sticks with them, gets them out of the situation they’re in into a better situation and then lets go of the casework, rather than doing a telephone assessment, passing it on to another team to do something specialist, and passing it on to someone else over there to do the equipment.”
“I know it sounds daft, but by reversing the normal, almost industrial chain of events, and just having one person in these innovation sites stick with the individual has proved a better outcome for the person, while the worker feels more holistic in what they’re doing and finally, they’ve spent less money.”
How Living Well is working on the ground
“I asked for some stories of difference to be sent to me and one of them is about our team in Great Yarmouth where, and this is really common, where a carer’s health has a crisis, the carer has to go into hospital and the person they’re caring for a person who is in their 90s has dementia, but relatively low-level dementia.”
“Normally that would come to us as a crisis because the carer has gone into hospital. We would then assess for respite care, put the person into respite care.”
“Instead of doing that we took time, got the worker to go out and stick with that situation for a couple of days and work through. In this scenario the worker went out and did a much more in-depth piece of work, stuck to them and understood their whole world, found that there are people in that street who were prepared to support them, neighbours and friends who know that person – plus there’s a family member in the vicinity.”
“So, we put together an informal network of people and some technology in the home which would trigger, so in that case the woman was able to be left, she didn’t often wander, the nature of her dementia meant she didn’t wander out, she stayed in bed. So there was an ability there to set an alternative in place rather than the tick box approach. In a way it sounds obvious, and it is, but we just are not doing enough of it.”
“I’m not saying there aren’t down sides to it as I think some people can come with an expectation that they need home care and that’s their determined view. I’m saying to the social workers that the Care Act and your own training tells you that you need to be challenging whether that is the right approach.”
“I absolutely see that a convenience in a family might be for formal care services where-as the answer for the individual might not be, so it is a trade-off and I obviously expect staff to show professionalism. So that’s approach number one – saving the money. Approach number two is the integration stuff.”
“I would judge success as this revised social work community-based model working. Us and the doctors being much closer together, having the habit of exchanging information about people who are at risk. I guess it’s easy for me to say but that national question about funding will be solved.
Because I think at the moment our vision is two years, three years. We need a ten-year, fifteen-year vision.”
One of the other big challenges James Bullion has faced is the council’s relations with the care providers it contracts to deliver services. Smaller providers in particular have been critical at squeezes in pay rates, and what they see as preferential treatment for NorseCare, the council’s wholly-owned arms-length subsidiary company.
John Bacon, chairman of Norfolk Independent Care, said while he supported the authority’s approach he had yet to see much material change on the ground.
However, he had noticed a willingness to engage with providers earlier in the policymaking process and he was keen to encourage that.
“Either they haven’t got it off the ground or there is a lag because we haven’t really seen any change from the providers perspective,” he says. “The biggest concern is home care. People with dementia are pretty reliant on home care, that’s the area where there is probably the most discussion going on.”
“They do pay more than other local authorities to be fair, but that’s still not enough. There’s a majority of smaller members that have propped up the council for a long time. They will either go out of business or exit the market. It’s unlikely they will be bought by other smaller operators, so it means there will be larger operators and therefore less leverage around purchasing power.”
One change he had noticed was that the authority was more willing to engage with providers earlier in the process which he felt meant that better solutions can be found collectively, but he felt this could go further still and yield even better results for all sides.
“There is a lot of really smart providers out there, and if the NHS and local authority can see those people as part of the team on projects with equitable rates of pay that will have really positive results.”
For James Bullion he is keen to work with providers not least to offset any problems before they become too serious.
“In terms of the market, we are investing in higher rates of pay and higher rates of contracting with the market to try and sustain it,” he notes. “But there is the risk that people might hand work back or go under, so we’ve got a dedicated message out there which is if you’re in trouble then come and talk to us. We have got an ability to respond to people who are in financial distress, and there’s a clause in our contracting that allows us to have a much more flexible conversation with a provider if they’re in trouble, but we don’t know that unless they come to talk to us about that.”
“We’ve got a formal tool that we use to assess risk of providers, we’re doing that all the time. We don’t just sit back and wait for people to come to us. We do look at providers and their accounts and nationally. As often providers are in a wider group and we have a systemised way of looking at that. And a lot of providers work with ourselves and Suffolk and Essex and Cambridgeshire so we talk in the region as well about particular issues we’re dealing with providers. But at the end of the day we have to be collaborative with them, we have to understand their businesses and try and support them. And I’d like to think we’ve created that atmosphere, people won’t fear coming to us. We genuinely won’t try to close anyone down. Even when there’s a quality issue, we might suspend placements, but we will come up with a plan to improve that.”
And despite the multi-faceted challenges he faces on funding and the future of social care services across the country, he says he has been galvanised by the role, and the chance to try and reshape the way things are done.
“I came back under tragic circumstances with Harrold Bodmer. But in coming back here, I came back with a passion I suppose about trying new things, about being business-like in the way we approach some of these social issues, and with my energy rejuvenated in that community approach.”