Comparative Evaluation of Programming Paradigms: Separation of Concerns with Object-, Aspect-, and Context-Oriented Programming Fumiya Kato, Kazunori Sakamoto, Hironori Washizaki, and Yoshiaki Fukazawa Abstract OOP, AOP, and COP and perform comparative experimen-tation on these paradigms to research their effectiveness of There are many programming paradigms for the sep- achieving SoC.
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Advice service top 5 issuesTen ideas to make better use of current social care funding while improving quality of care and experiences for Introduction Counsel and Care recognises the huge financial pressures currently facing local authorities in England. These pose a great threat to the provision of services and support for older people. With the public deficit currently standing at £6,000 for every household in the country and local government alone expected to make £1.165 billion1 worth of savings, we recognise that times are going to be tough for all public services. However, this drive for efficiencies must not be to the detriment of older people with care and support needs and their families and carers. The primary focus must always be on improving quality and improving experiences for older people, their families and carers, not on cutting vital frontline services. The current care system needs to be radically reformed. However, until that is done, in this world of budgetary pressures, it is important to identify how better value for money could be achieved from current spending on social care. Counsel and Care has compiled a list of ten ways to make better use of care funding. These ten ideas suggest how to create a ‘smarter’, more innovative and, ultimately, more effective social care system for older people, their families and carers. We believe that better care could be delivered at the same time as saving up to £3 billion – money which could be re-invested to meet growing demands. This must be done as a matter of urgency; we cannot afford to wait for long-term reform of the care system. Better value for money could be achieved from current care spending by re-focusing resources on: 1) providing easily accessible advice, information and advocacy 2) recognising the key role that families and carers play 3) specialist independent financial advice 4) supporting people to stay or move to where they want to be in later life 5) integration of housing, health and care 6) new technology: telecare and telehealth 7) personalisation: making sure care is focused on the person 8) prevention, early intervention and homechecks 9) volunteering and intergenerational work 10) dementia drugs and treatments 1 House of Commons Hansard Ministerial Statements for 26 May 2010: http://www.publications.parliament.uk/pa/cm201011/cmhansrd/cm100526/wmstext/100526m0001.htm The challenge is for central and local government to use existing resources intelligently, effectively and fairly, with a clear focus on outcomes. While good practice shows that some of what is needed is already happening, it is patchy and insufficiently joined up with wider service provision. Smarter spending could save up to £3 billion and deliver better care. These savings should be re-invested to meet the growing needs of our ageing population. 1) Providing easily accessible advice, information and advocacy Investing in advice and information is a key way to make the current care system work more effectively to support older people and their carers earlier. Much waste and repetition could be avoided and money saved by ensuring that all older people can get the care and support they need at the right time and in the right place. Currently 29% of people with disabilities using social care services say they are not communicated with in a way that enables them to understand their care and treatment properly, according to Care Quality Commission’s first annual report to parliament on the state of health care and adult social care in England2. The current care system is complex and confusing. As a result, there is a wealth of different options to choose from and possible pathways to take. Older people, their families and carers often need considerable assistance to navigate the system. By the time they have access to the right information and advice for their particular circumstances, they have often made a lot of wrong turns and wasted time and money. Good advice is about explaining and interpreting the wealth of information available and advising the individual as to the best way forward depending on their situation. Access to such information and advice at an early stage has the power to improve a person’s overall experience of services by supporting them to make the right choice about their care from the start. It has the potential to create savings by preventing them from reaching crisis point and being forced to access costly acute hospital care as a result. It also can encourage a person to maintain their independence by having better choice and control over how their care and support is provided. Some older people need extra support through independent advocacy to speak out and secure or exercise their rights, choices and wishes. Access to such 2 The state of health care and adult social care in England: key themes and quality of services in 2009, Care Quality Commission, February 2010 advocacy must be promoted and facilitated whenever possible for older people, both for those who have support from family as well as those who do not, in order to help them make the best choices about their care and support, and raise any concerns they may have. Local councils and private care providers both have a responsibility to ensure that older people, their families and carers are fully supported to access good quality, independent advice, information and advocacy that can be tailored to their individual situations. Nationally a single ‘care direct’ web and telephone portal could reduce duplication of effort and provide one point of call wherever people live. 2) Recognising the key role that families and carers play If cuts are made to the limited support currently available for carers, both the social care system and the economy are at risk of grinding to a halt. Currently, over six million carers struggle daily to hold up the creaking care system. Carers, particularly older carers over 60 of which there are more than 1.5 million3, do not always self-identify and, therefore, do not know what the person they are caring for is entitled to, nor what they as a carer can access if they are eligible for it. Local councils and primary care trusts, together with voluntary organisations, must work to promote the rights of carers and clearly identify the range of support that is available. If more support can be given to carers, both financially with better carers’ benefits and allowances and practically with access to training and services, to make sure that they can continue in their caring role rather than collapse under the strain, more resources can be used elsewhere in the care system. Flexible respite care would help carers to cope, particularly with emergencies. In addition, carers of adults who wish to continue working should be eligible to care vouchers from their employers: a tax exemption which would be used to purchase care and support in the same way that childcare vouchers currently work. 3) Specialist independent financial advice As the system for funding care is so complex, there is a lot of specialist financial advice available about how people can protect themselves against the future costs of long-term care through financial products like immediate needs annuities. However, the vast majority of older people, their families and carers are not aware of the existence of such products or cannot access specialist and independent financial advice due to the cost. 3 Carers UK and Sheffield Hallam University (2005) Older Carers in the UK. Carers UK, London The range of available financial products must be encouraged to expand and diversify so that older people can pick a financial option that can be tailored to their specific individual needs without risk of adverse results. The existence of independent financial advice also needs to be more actively promoted to the general public to encourage take-up of suitable and regulated financial products. In this way, older people who do have to sell their property to pay for their care can invest the capital they release from the sale in appropriate products. The products must make sure that the person can pay for all their care fees in full without the worry of their money running out while also giving them the option to set money aside for an inheritance if they so wish. A single portal to help older people and their families access independent financial advice on paying for care should be created. 4) Supporting people to stay or move to where they want to be in later life Moving into a care home can be a positive choice for many older people and, certainly, if an older person requires acute medical attention, a hospital is the best place for them to be. However, all too often, older people move into a care home or have protracted stays in hospital when it would simply not be required if there were practical and suitable alternatives for them to choose from. Much emphasis has been made on the potential cost savings to be had if more resources are focused on keeping older people out of institutions, such as a hospital or a care home, and supporting them to live in their own home for as long as possible4. In order to ensure that older people can make the best choice for their future care depending on their individual care and support needs, more community-based options are required as viable and workable alternatives to a care home. If commissioners look to invest in reablement and rehabilitation, there is potential for considerable longer-term savings to be made. Current models of intermediate care go some way towards this but further development of these support systems is needed. Local councils should move beyond care to focus on ‘reabling’ older people to live their lives as fully as possible. Councils should identify older people in their area who may be able to benefit from up to six weeks free reablement in order to regain their independence wherever possible, as well as then receiving some ongoing care and support when appropriate. The work being carried out in Hampshire to implement its ‘model for personalisation’ is one good example of a council that is focusing on early 4 Department of Health, Use of Resources in Adult Social Care: a guide for local authorities, Department of Health, October 2009 intervention and prevention. As a result of their reablement programme, last year over 50% of those people discharged from hospital to Hampshire council’s ‘Time to Think’ reablement beds were able to return to the community, compared to a prediction of just under 6% at the point when the people were discharged. In addition, their Community Response Team assessment and six week reablement service was able to provide care and support to over 3,000 people at home during 2009. Further investment in frontline home care services by councils rather than efficiency savings can also provide significant long-term savings. Through easier access to better quality home care services older people can be supported to remain in a more stable situation at home rather than requiring acute care in a crisis. There was potential for around 130,000 older people to access reablement support as a result of the Personal Care at Home Act. The savings made from the non-implementation of this Act should be used to stimulate smarter spending. 5) Integration of housing, health and care It is crucial that there is closer joint working between health, housing and care services to make the best use of resources and encourage a joint focus together on delivering both preventative and personalised care. In particular, there is great capacity for the social care system to be further integrated with the National Health Service and housing with immediate benefits for services, such as hospital discharge, intermediate care, sheltered and extra-care housing and occupational therapy. In this way such services can work more effectively together to ensure seamless transitions of care and support for older people, from acute care back into the community. In reality, this could reduce the number of older people having to give up their home due to ill-health or disability as they can get the right equipment, care, appropriate housing and housing adaptations in the community. It also has the potential to reduce the number of people who have to access acute health services or make a permanent move into a care home if they prefer not to. There is some good practice on integration of housing, health and adult social care, but it remains patchy. Enquirers to Counsel and Care’s Advice Service continue to complain about the complexity of the health and social care systems and the amount of different hoops that a person has to jump through before they can get access to the care that they need. Joined-up assessments are needed in order to simplify and streamline the care system for older people, their families and carers and to make sure that they can access good quality care they need in the quickest possible way. A commission of inquiry has been set up in South Essex to encourage closer co-operation between housing, health and adult social care. It aims to set up a joint concordat with a shared agenda for delivering personalised services across the public, charitable and the private sectors. However, the Audit Commission Under Pressure report highlighted that most councils remain unaware of the savings that can be achieved from ‘preventive and collaborative action’5.The Audit Commission has indicated how partnership working across a range of agencies responsible for housing, health and social care can encourage better quality of care. It encourages councils and NHS trusts to work together to set up more pooled resources and more aligned budgets (where the money is kept separate but joint decisions are made)6. Setting up joined-up processes between health and care can be a challenge due to clashing organisational cultures, computer systems and financial processes. However, good practice has shown that these challenges can be overcome. Once joint processes are established, integration has been shown to be an effective way to reduce duplication and waste, while at the same time improving the experience for older people and their carers. The Audit Commission has recommended that a tool be developed together with the Care Quality Commission to more accurately measure the outcomes of more integrated budgets and partnership working in terms of better value for money and improved overall experience. In addition, the 13 Total Place pilot areas are working to root out overlap in public services and in so doing to deliver not just better value for money but also better local services. To ensure success local providers in the pilot areas have been incentivised to work together to attempt a radical re-design of the way public services are planned and delivered at local level. It is important that the learning and good practice developed in the Total Place pilot areas are promoted by central government and widely disseminated. 6) New technology: telecare and telehealth The government should consider increasing investment in new technology to help more older people live in their home with safety and security. Telecare and telehealthcare have the potential to save money and create a more efficient care system, while also improving the quality of life for older people, and their carers. Evidence from Scotland – independently evaluated by York University – shows that telecare in people’s homes can reduce the number of days needed in hospital stays and delay entry to residential care as well as saving on home 5 Audit Commission, Under Pressure: Tackling the financial challenge for councils of an ageing population, February 2010 6 Audit Commission, Means to an end: joint financing across health and social care, Health national report, October 2009 checks and visits7. The savings add up to £5 for every £1 invested in installing a range of electronic communications equipment in older people’s homes. Evidence from local authorities and primary care trusts in England – from Stockton and Sheffield to North Yorkshire and Sunderland – shows how telecare is helping transform care for older people while saving resources that can be re-invested in care and support for the ageing population. According to the Audit Commission, one county saves £1 million a year on residential care costs by providing telecare services8. In order to be effective, future investment in telecare needs to be substantial, well planned and mainstreamed by local councils in order to transform health and social care for older people and their carers. 7) Personalisation: making sure care is focused on the person We welcome the government’s pledge to extend the roll-out of personal budgets to give people and their carers more control and choice over their care and support. However, there needs to be more support, brokerage and tools available to help older people and their carers understand what ‘personalisation’ can actually mean for them and how it can benefit their lives. Counsel and Care has concerns as to whether the required levers currently exist in the care market to encourage growth of new and innovative services that will enable people to get the most benefit out of their personal budget. Local authorities have a key role to play in this as market shapers in their areas. 8) Prevention, early intervention and homechecks As a society we are living longer, but with increasingly complex and challenging health needs. Medical advances mean there are growing numbers of people living with long-term, sometimes multiple conditions. By promoting healthier lifestyles in later life and investing in preventative programmes, the government has the capacity both to improve the quality of life for older people and their carers, and shift the focus of the NHS towards preventing illness, not just treating it. A greater focus on prevention should include free ‘safe and secure at home’ checks by a range of agencies, as well as personal health MOTs for the over 65s, which should emphasise what people can do for themselves to prevent some of the most common and serious conditions such as strokes, diabetes, heart conditions and so on. Enabling people to manage their own long-term 7 Counsel and Care press release, ‘Investing in telecare could save £5 for every £1 spent while improving the lives of millions of older people and carers’, Counsel and Care February 2009 88 Audit Commission, Under Pressure: Tackling the financial challenge for councils of an ageing population, February 2010 conditions could reduce the need for much more expensive health and social care. 9) Volunteering and intergenerational work Older people are more likely to volunteer to support local communities, according to the Audit Commission9. This is an untapped resource that if better utilised would be of great value to the future of public services. Counsel and Care estimates that £70million of public funding, together with levering in an extra £50 million from non-statutory sources, could enable 480,000 older people to access the benefits of befriending, supported by 240,000 volunteers10. One in ten older people report feeling lonely all the time and with about 3.7 million older people living alone11, loneliness is likely to grow. Befriending can provide valued social contact, signposting to other services and real early intervention to prevent crises. Extrapolating the costs of running the award-winning Neighbourhood Care Scheme in Brighton and Hove12 suggests that £120 million across the country would benefit both older people and volunteer befrienders as well as saving on huge health and social care costs.13 Befriending is so cost-effective that better promotion and funding of schemes across the country are really affordable ways of preventing isolation and loneliness for older people. It also enables older people to retain or regenerate their social links and to continue to contribute to the local community for the mutual benefit of the whole of society. We also need to review the use of local community facilities and make better use of this infrastructure. For example, if the 3,500 children’s centres in England were to share their site with support and activities for older people in the community, big savings as well as intergenerational benefits could be achieved. Some shared sites have already been developed, for example, in Merton and Surrey. 9 9 Audit Commission, Under Pressure: Tackling the financial challenge for councils of an ageing population, February 2010 10Counsel and Care press release: ‘Befriending could transform life for half a million of Britain’s loneliest older people’, Counsel and Care, 19 March 2010 11 General Lifestyle Survey 2008, table 3.3, Office for National Statistics, 2010 12 The Neighbourhood Care Scheme is a good neighbour scheme in Brighton and Hove that supports older people, people with physical disabilities and carers by recruiting local volunteers to support them in a variety of ways. For more information visit the website at: 13 Counsel and Care press release: ‘Befriending could transform life for half a million of Britain’s loneliest older people’, Counsel and Care, 19 March 2010 The number of people living with dementia is now estimated to have risen to 741,000 in 2010 and will rise to 755,000 in 2011, according to the Alzheimer’s Society’s latest position statement. The Alzheimer’s Society is now using the new estimate of 750,000 people living with dementia in the UK.14 As a result of these worrying statistics, NICE should look again at the use of certain drugs (donepezil (Aricept), galantamine (Reminyl) or anrivastigmine (Exelon)) that have been proven to reduce the impact of dementia for people in the early stages of Alzheimer’s disease. NICE has recommended that these drugs should only be prescribed under NHS care to people with moderate, but not mild, Alzheimer’s disease. It is important to consider the quality of life improvements for a person and their carer and the possible cost savings if a person receives treatment which delays the progression of the disease and reduces the amount of care and support they require. Counsel and Care supports the Alzheimer’s Society’s campaign for drugs to be made available to those who can benefit from them. Access to such drugs can significantly improve the quality of life for many people with dementia and their carers while reducing the need for much more expensive care. More funding for specific dementia drugs must also be accompanied by more funding for dementia care training and education for health and social care professionals. In this way, the option of prescribing dementia drugs to people with dementia can be considered in a balanced way alongside the use of other beneficial non-pharmalogical or psychological approaches and therapies. Recommendations To achieve smarter spending for better care, Counsel and Care recommends that we need: strong and urgent leadership at national and local level swift implementation by local commissioners and practitioners investment in reform from the social care transformation programme and savings from the non-implementation of the Personal Care at Home Act joined up care, health, housing, with budgets pooled on Total Place 14 Alzheimer’s Society position statement on demography: Counsel and Care is the national charity working with older people, their families and carers to get the best care and support. advice and information, which informs our research and campaigning work. Counsel and Care Twyman House 16 Bonny Street London NW1 9PG telephone: 020 7241 8555 email:ADVICE LINE: 0845 300 7585 (local call rate)
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