Written evidence submitted by Colin Slasberg (independent Researcher and Consultant in Social Care at The campaign for Real Care); Charli Thompson (ASC0025)

HEALTH AND CARE SELECT COMMITTEE

THE COST OF INACTION ON SOCIAL CARE REFORM

This submission addresses the following two questions

‘What is the cost of inaction to individuals and how might people’s lives change with action on adult social care reform?

Where in the system is the cost of inaction on adult social care reform being borne the most?

SUMMARY

The cost to the people who rely on the unreformed social care system and to the taxpayers who fund it are in both cases immense.

Social care’s leaders state that funding levels leave councils able to meet only crises and highest needs. They have no money for prevention. But there is a huge difference in how much councils spend per individual. The 10% highest spend nearly double the lowest 10%. Yet they too are able to meet only crises and highest needs. It would cost some £6BN for all councils to spend the same as the highest. But there can be no confidence they will not all still be engulfed in crises and high needs.

Crises and highest needs expand to the available resource.

Public money is being mis-spent on an industrial scale.

Only the small minority with the skills and energy to use a cash payment to employ their own care, support and assistance workers can be routinely relied on to know how to make best use of public money.

Whatever the merits in reform of the charging regime it will make no difference to the quality of a system that does not know how to use its resources. It cannot be known by how much capacity needs to be increased until the system uses its existing resource to best effect. The reform required is fundamental. It will not in itself require more money. But it will require political will.

The Campaign for Real Care is led by a group that integrates knowledge from the experience of receiving social care, professional experience and academic endeavour

Clare Blunt, unpaid family carer and paid Personal Assistant

Don O’Neal, disabled person, employer of Personal Assistants and author of book - Lack of Care Act

Colin Slasberg, qualified social worker, PhD student, independent researcher and consultant in social care

Charli Thompson, disabled person and unpaid family carer

Mark Williams, disabled person, employer of Personal Assistants, Chair of Bristol Reclaiming Independent Living Alliance, qualified but not practising social worker.

1. Over the past five years, the Campaign has been building a dossier called Social Care Exposed. It will be ready for publication early in 2025. It will have six parts;

a. Parts 1-3 will show how the public messaging from councils and social care’s leaders about how social care works are entirely misleading. Building from a forensic examination of two councils, the dossier will show the public messages create a façade built on good practice that serves to conceal a reality built on what social care leaders know to be worst practice. It will show how these two councils are not rogue, but delivering the national template and at huge human cost.

b. Parts 4-6 will set out the seriously damaging consequences in relation to the use of public resources.

2. Social care’s leaders and policy makers have known for a long time that the best outcomes for older and disabled people in need of care and support happens when resources are allocated to the unique needs of individuals in a way that builds on their strengths and their aspirations to make their lives the best they can be. In other words, the system must be personalised. They have also known that the resulting independence of individuals means the least demand on public resources.

3. This ‘win-win’ of such a system has been the ambition of policy for three decades. The Community Care reforms in the 1990’s and personal budgets through up-front allocations of the noughties both failed to bring it about. Following the failure of the latter, strategy has shifted to changing the way social workers assess needs and plan support. Strategies are based on a combination of exhortation and training.

4. Councils expend considerable time, energy and money on management and training consultancies to bring about this transformation. However, they cannot and will never succeed if they maintain this strategy. They assume that social workers’ poor practices have been a professional choice. But no basis is offered for that assumption. None exists. No explanation is offered as to why social workers should have, en masse, abandoned their professional code of ethics, values and training through choice.

5. The bad practices are in reality the product of the policy environment within which social workers practice. It creates irresistible systemic demands upon them. The key feature is that all needs calling for public funding must be met as a matter of legal obligation. No need can be left unmet. This defines the ‘eligibility’ regime. A personalised system would require decisions about resource allocation to be rooted in the scale of impact on outcomes, specifically wellbeing. But the cliff edge, in-out decisions of the eligibility regime makes greatest risk the defining factor. This requires need to be defined in terms of deficits, not strengths, on dependency not independence and on resignation not aspiration.

6. The level of risk must be calibrated to whatever the local budget happens to be. The large differences in both the numbers of people needing care and support per population and in the available budgets per population accounts for the huge scale of the ‘post code lottery’.

7. Although the policy is presented as a requirement of the Care Act, it is not. Paradoxically, it is actually contrary to the Act[1].

8. However, Directors are keen to cling to the policy. It provides a powerful weapon in their internal negotiations for budgets. They can use it to threaten legal jeopardy if they are not provided the budget to meet all assessed needs.

9. Thus Directors have been able to succeed in securing yearly increases in budgets for demographic growth, mostly in the older population. On the premise that the previous year’s budget was sufficient to meet all eligible needs (given eligibility is calibrated to the budget, that is, of course, always true), this year’s budget must be the same plus an addition for increases in inescapable demand.

Thus for the current year, increases in budget were secured to the value of £801M between all councils, about 4% of net budgets[2].

10. However, in return councils insist the increases must be paid for by Directors through efficiency savings. For the current year, these amounted to £903M. Directors say they will deliver the savings through transformation of practice from being deficit to strengths based.

11. Over the past 10 years, the total of such ‘efficiency savings’ has exceeded £10BN, more than half the annual gross spend on long term care. It is offered up year in year out in a ground hog day cycle of repetition. A blind eye is turned to the absurdity of this being clear evidence the transformation has never happened.

12. How many Directors nonetheless truly believe the transformations have or will happen is not known. There are, however, two further signs they have not and will not;

a. Many councils have appointed full time officers and teams with the word ‘transformation’ in their titles. This points to ‘transformation’ being not the one-off event it must be if authentic, but a permanent feature

b. Many have adopted ‘co-production’ policies. What would be a spontaneous consequence of best, person centred practice has become bureaucratised.

These strategies enable Directors to tick the boxes of change.

13. The net effect is standstill budgets. The gross spend of £28.4BN in 2022/23 was virtually the same in real terms as the £18.8BN spent in 2009/10.

14. Directors will be entitled to regard this, by fair means or foul, as a success given it has occurred during a period when fellow services have suffered savage cuts. However, this success is undermined not just by the perpetuation of the dysfunction at the heart of social care, but by two other factors;

a. the 2010 level of spend was already leaving large swathes of needs unmet. The Kings Fund estimated it to be worth £7BN b. the deficit led assessment practices that remain endemic are resulting in the creation of dependency and therefore demand, making the worst possible use of public resources

15. Social Care Exposed will compare the data for demand and provision for the highest and lowest spending councils. They will show how the highest spending have more money to spend on fewer service users per population but use the money to simply place a far higher percentage of people in institutional care and pay the providers much more to do so. They achieve the least level of independence and at the greatest cost.

16. The Campaign for Real Care believes the transformational change required is for social care to adopt the same principle as the NHS in the reconciliation of needs and resources. This would be fully supported by primary legislation in the form of the Care Act. The professional role must be to identify individual need against the political vision of how life should be. In addition to thus being able to make the best use of the existing funding, professionals will also be able to ensure the political system is aware of the funding required to make a reality of the political vision.

The change can be captured in a Charter for the Right to Wellbeing. The Charter can be the centrepiece of a new Constitution for Social Care to sit alongside the NHS Constitution.

[1] Section 9 of the Act requires all needs calling for public funding to be assessed regardless of available resources; assessed needs are then divided between those that are a legal duty to meet (section 18) and those that are power to meet (section 19). The legal duty should be a minimum only, not the total offer.

[2] The ADASS Annual Spring Survey o f Budgets

December 2024