Lessons from two starkly different reports on social care

Published by Professional Social Work magazine - 12 August 2019

Last month saw the publication of two reports that provide key insights as to the thinking of political leaders about social care.

One is from the House of Lords, via its Economic Affairs Committee. The other is from the Commons, via an All-Party Parliamentary Committee. They reveal quite different views.

The Lords committee sees 'a national scandal'

The first to publish was the Lords report under the title – Time to end a national scandal. The report is clear that its focus is on the funding issue. A key recommendation is that personal care should be free, as is the case in Scotland. 

It might have been better to have learned from the Scottish experience where the distinction between personal needs – such as washing and dressing - and other needs for care and support has proven artificial and contentious. 

Few, on the other hand, would dispute that people should pay their own accommodation costs. This would, indeed, restore the original intention of the 1948 settlement which established the principle of how public and private funding should work together. 

The State would pay all care costs, and the person their own ‘hotel costs’, albeit with help from the new State pension for those without a private income.

Nonetheless, making personal care free would be a step in a direction that all those with the interests at heart of the people who need care and support will welcome.

The Lords report recognise that their focus on funding meant their report “does not consider issues of quality or the nature of provision of care”. Indeed, as a group concerned with economic affairs, they may have seen such matters outside their remit.

However, they found it is not possible to entirely separate funding from the nature of provision. The committee were particularly concerned about inequity, noting "a postcode lottery" in provision. 

The report quotes from evidence given by Shaping our Lives, an organisation that represents service users, which accounts for the problem.

"If a council deems a need to be ‘eligible’ the need must be met as a matter of legal duty without delay. However, councils have carte blanche to define ‘need’ in whatever way they want.

"There are national eligibility criteria, but these are so loose as to be virtually meaningless … In this way councils can meet their fiduciary duty to spend within budget. In effect, it is significance of impact on budget, not wellbeing, that determines whether needs will be deemed ‘eligible'."

The Lords committee sees a system seriously underfunded, with inaction leading to increases in "the level of unmet need in the system".  It notes that there have been decades of "failed reforms".

The Commons committee takes a very different view

The report from the Commons committee, on the other hand, does address the nature and quality of the service. But the tone contrasts starkly.

The report sees a "thriving and responsive sector", where a great deal of innovation takes place with "a diversity of high-quality providers and services". None of their eight recommendations directly addresses funding levels or the balance of private and public funding.

The report’s confidence reflects the messages consistently conveyed by social care’s leaders. It rests on three factors - satisfaction ratings by service users, the sector’s capacity to innovate, and the ability of the personalisation strategy to “transform lives”. There are serious problems with each.

Satisfaction ratings

Reassurance is taken from satisfaction ratings based on surveys administered by the sector itself.  Results are generally positive.

Satisfaction, however, can only be understood in the context of expectations. Most service users are in situations that, without support, would be truly frightening.

The person may be grateful to simply survive. Oliver Twist may been alone in declaring he was not satisfied with his rations, but he was not the only one.

Innovation – transformative or peripheral?

The report outlines six different schemes. They range from a work with housing to promote safety in the home to a system to secure the views about their care of residents in a residential home.

The schemes are all worthy with much to commend them. However, they exist on the periphery of the mainstream system. They do not address how the mainstream system spends the £20bn with which it is equipped to identify and meet needs.

Personalising the mainstream system – the false narrative

The committee expresses complete confidence in the personalisation strategy to ensure the mainstream system offers personalised support. It sees this "in the form of personal budgets or direct payments… for the opportunities they can create to empower people, so they can take more decisions about their lives". 

The problem is that the committee seem unaware that personal budgets do not exist, and the direct payments only work for the minority who use their payment to employ their own staff.

The National Audit Office reported in 2016 that some councils have ceased calculating up-front allocation of money, and where councils still did, social workers were not sharing it with the service user because they were "inaccurate and unhelpful".

The up-front allocation was the foundation stone of the personal budget strategy. Without it, the process collapses, and the strategy does not exist.

The phrase ‘personal budget’ has now firmly entered the sector’s vocabulary. However, it now means something completely different. It is nothing more than a financial costing exercise that takes place at the end of the process. It is simply the cost of the services the council has decided to offer. This, indeed, is the very modest role given it by the Care Act. It is stripped of any transformative value.

Direct payments benefitting only a small minority

Think Local Act Personal, the body charged with overseeing implementation of the personalisation strategy, carry out regular surveys of people using services.

The surveys have established that it is only when direct payments are used by service users to employ their own staff that they deliver a personalised service. When people use their direct payment simply to pay the invoice of the regulated services they would have got anyway, it makes no difference.

Under the personalisation strategy, the number of people with a direct payment has trebled. Some 15 per cent of service users now have a direct payment. However, we know that less than a third of them now employ their own staff.

Delusional and complacent

The net effect is that only some five per cent of service users are experiencing personalised support in the way the committee understands. This is no different to what has been the case since the mid-1990s when the direct payments legislation was introduced.

This leaves the MPs' view that personal budgets and direct payments are delivering personalised supports as little short of delusional. It’s a delusion that leads to complacency and inertia.

Innocent error or intent?

Whether this is an innocent error, or a matter of intent is a moot point. The delusion serves interests at their most cynical well.

It is ensuring the sector remains in the grip of a system that standardises and reduces what is deemed ‘need’ until demand matches resources, whatever the level of resource relative to the needs of the community.

It’s a system that always denies there is ever a gap between needs and resources. This is the eligibility system in operation.

It is, however, a system that disempowers, depersonalises and feeds on peoples’ weaknesses rather than building on their strengths. These are the evils that provided the rationale for the personalisation strategy a decade ago. The failure of the strategy means they still exist.

Political leaders who proclaim there should be ‘greater’ or ‘adequate’ funding but who support the perpetuation of this system are at risk of uttering warm but worthless words. It will amount to little more than, at best, a few more crumbs from the table.

Conclusion

Service users, as surely will social workers, will welcome the Lords’ commitment to free personal care and its vigorous commitment to adequate funding.

There is rather less to commend the Commons report. Not until MPs come to terms with the failure of the personalisation strategy and the need to bring an end to the era of the eligibility process will they begin to deliver what they say they want to deliver.

Colin Slasberg is an independent social care consultant

This Viewpoint 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