Joint authors:

Colin Slasberg Consultant in Social Care

Peter Beresford visiting Professor University of East Anglia

In September, while the Health and Care Select Committee Inquiry into funding for social care was still sitting, we wrote an article highlighting the case of Anna Severight. The Committee played a clip of Anna’s testimony to Matt Hancock, Secretary of State. Anna is a 34 year old disabled woman who receives enough support to be ‘fed and watered’, but not enough to have a life ‘worth living’. Hancock noted this was a sad example of people not getting ‘all they would like’.  He thus failed to recognise that having a life worth living is something very much more than what people ‘would like’, a mere wish or want. Characterised by dignity, control over life and services and being able to engage in society a life worth living is a need recognised in the law by the Care Act.

We had prepared a submission to the Inquiry to give them advanced notice of the issues and how councils, encouraged by central government, are ignoring what the Care Act requires. We wondered in September whether the Committee when it finally reported would correct Hancock and identify what needs to happen to address Anna’s plight.

What the Select Committee says

We now know. The Committee’s final report, encouragingly, opened with Anna’s story as powerful testimony of the system’s failings. It then proceeded to do nothing about it. The Committee concluded the system needed £7BN more to meet demand from demography and to pay care workers what they should; £5BN more to make personal care free; £3.1BN to introduce a care cap.

Although not much more than government has recently found to fund its failing track and trace system, such increases would represent more than doubling of current spending on social care. Even so, the Committee’s proposals would not give a single penny toward giving Anna the support she needs. Indeed, if a care cap and free personal care are introduced and not fully funded – which on past precedent is a high risk – Anna’s chances of a normal life would reduce even further. The increased gap in funding would be made up through yet further restriction of eligibility.

Here is the nub of the issue. The eligibility regime has long allowed councils to adjust ‘need’ to their budget. When NHS clinicians make their diagnoses, the essential ingredients are the patient and the clinician’s knowledge and judgement. If not always working perfectly, the founding NHS principle that need must precede resources provides the policy context. As need outstrips resources, so waiting times go up. Not so in social care, where the equivalent of the clinical diagnosis is assessment of need. Whilst social workers gather information about the person, it is managers with responsibility for budgets, often working through ‘panels’, who make the decision as to whether a need is ‘eligible’ and therefore will be met. This enables councils to control the flow of demand to ensure spend matches budget. Councils, unlike the NHS, are permitted neither overspends nor to leave any need unmet.

In an almost absurd denial of the empirical evidence of this reality councils hotly deny it. They claim the eligibility decisions are the social worker’s, are entirely based on need and resources never come into it. That they are able to get away with this is due in no small part to political leaders having no interest in challenging them. It is a system that keeps the lid very firmly on demand, whilst silencing the voices of the older and disabled people within. It’s a system that suits those political leaders indifferent or even hostile to the needs of older and disabled people who want to keep the pot as small as they possibly can get away with. It also suits more liberal or more generous leaders who want to make the pot a little larger, but who don’t want the true limitations of their generosity exposed. They are able to secure virtue from comparison against the worst of their kind, not comparison with the best of what older and disabled people hope for.

Can there be a different future?

One view that is strongly pressed is for Independent Living to become a legal right. Independent Living as defined by the United Nations is indistinguishable from the Care Act’s vision of control, dignity and participation. At the moment, making independent living a legal right can seem a utopian ideal that no-one with the interests of older and disabled people at heart will disagree with. However, under our present politics, its prospects of happening in any foreseeable future are remote. The huge variability in individual costs will mean the service would have to be delivered on an ‘open cheque’ basis if councils will be under a legal obligation to meet every need for independent living. Given that service users’ quality of life doesn’t even make it into the top political priorities if the cross Party Select Committee report is anything to go by, the prospect of Parliament giving councils blank cheques to make independent living happen is very distant.

We will continue to make the case for an end to the eligibility regime as the source of much that is rotten in the social care system. But we do so having accepted that spending will still have to be controlled given it must take place within budgets which have been democratically determined.

Spending should be controlled in a very different way. Councils should assess and cost all needs as the Care Act requires – in effect all needs for independent living. Councils must be honest about which needs they can and which needs they cannot afford to meet. Political leaders should know how much funding they need to make available so that Anna and the many thousands like her have the life right for them. Political leaders should no longer be allowed hide behind their officers disappearing needs that the budget they have given officers is insufficient to meet. Political leaders must be held publicly and transparently accountable for the quality of the lives of their older and disabled citizens.

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2 Comments

  1. This is so to the point of what I call the “targets” issue. Assessment of need is not really an assessment of NEED or nominal value. This is something only the user knows and something that the skilled carer/social worker must ascertain. It is where the successful care process begins.
    Assessment of need is a managerial expression disguising a target that largely has to do with costs, scale of provision or governance. The real demand or value demand is captured in Independent Living. That should be the aim of every policy and that is what we need to measure performance on.
    On the money side the NHS has had to pay about £5.4 billion for delayed days in the last 9 years of which a beleaguered social care has generated over 60%. Now, cutting that back by 50% would help kickstart the £15bn funding. After all reducing DDs was on key Jeremy Hunt target in his Mandate!
    Great article

  2. Colin Slasberg says:

    I fully agree, John, with your view of the eligibility regime as symptomatic of the ‘target’ or ‘command and control’ culture. I have read your posts on the dysfunctional effects of this way of managing. A further point about the dysfunction of the eligibility regime is that putting people into the ‘eligibility’ boxes rather than matching resource to authentic, individual need is extremely inefficient. According to the Local Government Association’s own data, whilst they all claim to work to same national criteria, the highest spending councils spend an astonishing 60% more per service user than the lowest (£17.5K against £28K) but with no discernible impact in terms of reputation or against any of the measures of outcomes.

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