How do you solve a problem like social care?

Published by Professional Social Work magazine – 2 October, 2020

This time five years ago the government was being warned of a “deepening crisis” in adult social care.

The talk was of “crunch time”. Ministers were sent a letter signed by 20 health and social care organisations warning years of underspending was “compromising the dignity, health and wellbeing of older disabled people, their families and carers”.

Reform was surely just round the corner. Then came Brexit and the focus of government shifted and a much-anticipated green paper to sort out social care kept getting kicked down the road.

Fresh hope came after the 2019 General Election with Prime Minister Boris Johnson promising to “fix the crisis in social care once and for all”.

Then came coronavirus – and attention once again shifted, despite the pandemic highlighting the need for social care as greater than ever.

Failings in the delivery of adult social care were recently underlined by the Local Government and Social Care Ombudsman. Out of 3,073 cases referred to it for investigation in the last year in England, one in seven were upheld by the watchdog.

It can be predicted with reasonable surety that behind those figures are many more thousands of other dissatisfied ‘customers’ who did not have the energy or will to take on the complaints process.

No one disagrees that there is a crisis in social care. But its Cinderella satus compared to health plus successive governments shying away from the scale and cost of addressing the problem has contributed to the neglect.

Devolved governments have started looking at different solutions. Both Scotland and Wales are talking about creating a national social service. The Westminster government is reported to be considering handing control of social care to the NHS in England.

While some argue for social care to be free at the point of service like health, BASW England recognises this is a complex debate.

In a submission to a parliamentary health and social care committee inquiry this summer, it warns of long waiting lists for non-urgent needs and diminished resources for preventative work.

The group adds: "We are also concerned that free social care could result in thresholds for eligibility being raised, resulting in greater unmet need."

So how have we ended up in the current crisis?

Chris Perry, a former director of social services, roots the rot that has led to the current malaise in the 1990 National Health Service and Community Care Act which bought in the purchaser-provider split and a contract culture.

“Since the late 80s health, and the early 90s social services, have been required to separate out the management of in-house provision from that of purchasing and commissioning.

“The intention being that it would encourage a mixed economy of care and force quality up and prices down.

“Providing of services has been increasingly going to the private sector while local authority social workers on the purchasing side have been forced away from social work as I understand it which is about using relationships to bring about change.

“They are being pushed more and more to rationing than providing services, having to assess for eligibility and need for a service within a landscape of cuts and limited resources in which they often have to say no.

“If they are saying no and there is a statutory requirement to provide the service, when people complain to the ombudsman it is going to uphold the complaint isn’t it?”

Perry adds: “Nobody becomes a social worker to say no.”

Businessman Roy Griffiths was recruited by Margaret Thatcher in the 1980s to shake up the system. His 1983 Griffiths Report paved the way for the 1990 Act and the shift in management culture to inject private sector principles and competition into health and social care. 

Perry, who is also a former non-executive director of a NHS Trust and an ex-director of Age Concern in Hampshire, says: “The problem is he believed people were motivated and can be controlled by money.

“There is no evidence to support that at all. People may apply to a job for the money, but once they have got the job they are motivated by job satisfaction and recognition. He just couldn’t understand that at all.”

Perry believes local authorities should be allowed to go back to working in partnership with the voluntary and private sector rather than purchasing services from them.

“When I was a director my fellow directors would say ‘why do you spend so much money in the voluntary sector?’. I would say ‘I don’t, I work in partnership with them and get more back than I pay’.

“We had a lot of partnerships where we each contributed. There was no formal contract, there was just an understanding that’s what they would provide.”

The contract culture has also altered the way charities operate says Perry.

“You used to go into partnership with the voluntary sector because you wanted innovation and development. Now they are in a straight-jacket because there is a contract saying precisely what they have to do.”

He is particularly sad about the impact the last 30 years has had on social work.

“I am a social worker. I went into social work because I wanted to work with people and help people. Thinking back to my social work career right up to being an area officer, the provision of services was a minor part of the role.

“Most of the time social workers spent counselling with therapeutic interventions. Now they have been forced to going in and assess a request for a service. It is very sad that social work is no longer social work as I understand it.”

The 2014 Care Act put a statutory duty on local authorities to promote people's wellbeing and independence. But the Local Government Association claims its ambitions have been thwarted by lack of funding creating an "eligibility-driven approach".

Colin Slasberg, a former assistant director of adult social services, agrees. He says: "Contrary to public messaging, there is in reality no uniform, national body of ‘eligible’ need that all councils deliver. Each council defines what is ‘eligible’ in light of 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."

The resource-led definition of need means there is never any unmet need acknowledged, says Slasberg. He calls for "honesty at the frontline" and an admission when needs can't be met due to lack of resource which would then shape public and political discourse.

BASW England's adult group also calls for transparent assesments "built around partnership working and professional judgement, alongside transparent financial decision-making with clear recording of unmet need".

Perry also believes social workers have a role to play by reasserting their role of providing therapeutic interventions rather than being gatekeepers of resource. This, he says, must be backed by supportive managers and smaller caseloads.

“When I was deputy director in Bolton and also South Glamorgan one of the things I did was to put senior practitioners on very limited caseloads. In Bolton they had caseloads of ten. You can’t imagine anyone on that now, but it gave them the time to bring about change.”

Against a backdrop of cuts, growing demand due to an ageing population and staff shortages, some might see this as pie in the sky. The impact of coronavirus plus whatever new social and economic pressures are bought about by Brexit could make it seem even more so.

But Perry believes social services departments need to look within themselves too for solutions.

“We can always do with more resources because demand is going up and the population is going up and the amount of money spent is going down, but you can certainly get far more out than what is currently achieved.

“It is possible to manage within budget. It is a matter of priority and where you put your resources. One of the things we had in South Glamorgan was we had more staff in direct face-to-face contact with clients than any other department because I stripped out the bureaucracy.”

Reduced bureaucracy and ensuring social workers having more time to spend with service users are both campaigning focuses of the British Association of Social Workers and the Social Workers Union.

With the government now expected to publish its proposals for social care reform in the New Year, it is important social work’s contribution to the solution is recognised.

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.