After the Election and Brexit, fixing broken social care system must be next

Professional Social Work magazine - 14 January, 2020

Now that the General Election is over and Brexit is getting done, there can be no excuse for the government not focusing on the next most pressing issue: social care.

Unlike Brexit and who to vote for, this is an area that gains widespread consensus in that pretty much everyone agrees the current system is broken.

An important step in reforming adult social care was the introduction of the 2014 Care Act which put onus on local authorities to provide services to promote people’s independence and wellbeing.

Alongside this was the introduction of the National Eligibility Criteria to prevent a ‘postcode lottery’ in provision of services.

Has it worked? Recent data published by NHS Digital for 2018/19 suggests not. An analysis of this is useful in helping us understand what needs to change.

How equitable is level of provision?

Equity is usually measured by spend per head of population served. However, as a measure this is fraught with difficulties. The demography of the communities councils serve varies in ways that impact hugely on demand. Not least is the level of deprivation. Councils serving the ten per cent most deprived communities last year had an average of 22.9 long-term service users per 1,000 adult population. Those serving the ten per cent most affluent communities had just 15.3. The most deprived councils serve 50 per cent more long-term service users than the most affluent.

The better measure of equity is the average spend per long-term service user. This tests whether people in Surrey and Salford with similar levels of need get similar levels of support. Adjustments have to be made for regional price differences which impact on the cost of care.

So what was the case last year? The ten per cent highest spending councils spent an average of £22,700 per person receiving long-term care and the ten per cent lowest just £12,900. The highest spenders spent 76 per cent more than the lowest spenders.

By far the biggest factor impacting on this was the number of long-term service users. The lowest spending councils had 25 per 1,000 population while the top spending just 16. The lowest spending councils had 56 per cent more long-term service users than the highest, meaning they had to spread their jam more thinly.

The single biggest factor driving the difference is deprivation. Whether due to more people being excluded from services by the means test or better general health enjoyed among their population, councils serving more affluent areas have fewer people needing social care support from them. As a result, they are able to spend more per service user.

What of effectiveness?

This great inequity does at least give us the opportunity to test whether more funding is the solution. If that were true we would expect the highest spending councils to achieve significantly better outcomes than the lowest spenders. Helpfully, NHS Digital publishes data about outcomes, including those based on surveys of service users.

The highest spending councils do achieve better outcomes against some of the measures. However, it is not by much and nowhere near matching the difference in spending. Overall service user satisfaction by was 65.5 per cent in the highest spending authorities against 63 per cent in the lowest.

NHS Digital also calculate the extent to which services are enabling the person to have quality of life. This is perhaps the most direct test of effectiveness. The scale is 0 to 1, with the highest scoring council achieving 0.49, the lowest 0.3 with a national average of 0.4. There was no difference between the highest and lowest spenders, with them both scoring an average at exactly the national average of 0.4.

Why does higher spending fail to improve outcomes?

The facts are counter intuitive. How can it be that spending so much more fails to improve outcomes? A clue might be found in some research carried out by Ipsos Mori into unmet need. Its findings were surprising.

The report found that getting help with practical, daily living tasks of the kind the eligibility process favours was far from being always welcomed by service users. Some said it undermined the “sense of resilience and independence” the researchers found was “associated with positive wellbeing, even in the face of unmet need for support with particular tasks”.

On the other side of the coin, people placed greater value on the type of social and leisure provision councils say there is no public responsibility to meet under the eligibility process.

This could be telling us that when need is defined by what people cannot do rather than what they aspire to, the resulting support has a depressing effect. Simply having more support focused on the wrong things does not improve wellbeing.

Conclusion

This situation is the inevitable outcome of a system described by the Local Government Association as the ‘eligibility driven approach’. Contrary to public messaging, there is no uniform, national body of ‘eligible’ need that all councils deliver. Each council defines what is ‘eligible’ based on their resources and the demands upon them.

Although carried out in the name of the Care Act, it’s a system that is frustrating delivery of what is arguably the Act’s most important and transformative provision. This is the requirement that councils identify ‘need’ in the context of each person’s wellbeing, not the council’s resources.

Assessing needs for wellbeing would, of course, create pressure on budgets. But instead of controlling spend by defining ‘need’ to match resources, spending could be controlled by decisions about how much of assessed need can be afforded. This can be done on a case by case basis. Thus, eligibility of need will be replaced with affordability of need.

The BASW England Consultation on the Future of Adult Social Care offers a four-step proposal to ending the eligibility-driven focus.

Such honesty at the frontline would then feed into the strategic arena with sector and political leaders then made aware of the gap between real need and resources. Under the current resource-led definition of ‘need’ there is never any unmet need even acknowledged.

Making it affordability-led means we can have a grown-up conversation about what needs we believe we can afford to meet and those we can’t.

Colin Slasberg is a former assistant director of adult services.

This article is published by Professional Social work magazine which provides a platform for a range of perspectives across the social work sector. It does not necessarily reflect the views of the British Association of Social Workers.