Written evidence submitted by Professor Peter Beresford and Mr Colin Slasberg (SCF0071)

Under the current system, beyond short term fixes to keep the system afloat, the question of what funding social care is required is both unknown and unknowable. This is for two reasons. Firstly the system shapes ‘need’ to resource as the means to control spending. This has the effect of denying information about true level of need for older and disabled people to have the quality of life we would expect for them. Secondly it is acknowledged within the sector that the system creates dependency, which means making older people old before their time and further disabling disabled people. This distortion of ‘need’ wastes an inestimable amount of resource. Both these ills must be righted before the question of social care’s long term funding requirements can be answered sensibly or with any confidence.

This submission summarises the key points from an article published this month in the Social Services Research Group’s journal Research in Policy and Practice. The article is titled A new start and sustainable future for social care. It presents an evidence-based analysis that exposes the web of enduring myths that dominate social care and keep it trapped in a visionless and impoverished state. The paper identifies the changes required. These changes can be made within existing legislation and within any funding level. The only risks are political. They are risks that can be reasonably expected of political leaders who care for the wellbeing of older and disabled people.

Our submission focusses on the impact of funding issues on the people who need social care. We address the impact on the NHS toward the end.

THE FAILINGS OF THE CURRENT SYSTEM

Overview

Social care is delivered within a budget. However desirable it would be for social care to be delivered on an open cheque basis so all needs for wellbeing can be met as of right, we assume that will not happen.

Working within a budget creates two imperatives for the service to be healthy. First it must achieve the greatest level of wellbeing for the greatest number of people in need of care and support within the resource available. Second, the system must generate information on a continuous basis so political leaders are informed of the funding required for all to have the level of wellbeing society expects our older and disabled citizens to experience.

The current system fails hopelessly on both counts.

Waste of resources. Sector leaders have long acknowledged that the system wastes an inestimable amount of resource by creating dependency. The sector holds social work practice responsible. In recent years strategies have been employed in all councils that exhort practitioners to change their practice to being ‘strengths based’. The evidence has been clear for some time that this strategy is failing.

Social workers were never to blame. There is a powerful systemic pressure that conditions social work practice. It is the eligibility needs test used to ration resources. The test is based on risk and is a cliff edge, in/out decision. Social workers and service users must look for matters to be as bad as possible to secure any support. At a moment of great fearfulness and vulnerability for the person, the eligibility test creates a gravitational pull into dependency.

Care and support should derive from the polar opposite. ‘Need’ should be seen in the context of people aspiring for their lives to be as good as they can be, regardless how dire their circumstances. Under these conditions optimism and independence are maximised and need for public resource minimised.

The belief that social work practice on its own can reverse the depressing and depersonalising impacts of the system is a buck-passing myth.

There is no information about real need. A founding principle of the NHS was that clinical need would precede resources. A lag between them is not only possible but likely. Waiting times and debt accrual provide the financial ‘safety valves’ the NHS front line requires to maintain the principle. The scale of waiting times also signals the gap between needs and funding upon which political leaders can choose to act.

Social care has no equivalent. Councils cannot accrue debt. Also, under the eligibility system councils are forbidden from failing to meet an assessed need. Under these conditions, the duty to spend within budget means councils have no choice but to define ‘need’ according to their resources. The resultant ‘needs test’ creates a circular definition of ‘need’. It means there is never a funding gap, no matter how great or small the budget relative to local need. It is delivered without regard to human cost.

Sector and political leaders deny that the eligibility needs is resource led. However, evidence that it indeed is can be found in the scale of the ‘post code lottery’. This is because matching spend to budget through a resource led process is inevitably locally driven. The needs test must deliver against the local budget. In 2018/19, the highest spending 10% of councils, having adjusted for regional price differences, spent an average of £22.7K per service user.  The lowest spent £12.9K, a difference of over 70%. These differences are not the result of random uniqueness of communities served. There is a pattern. The highest spending councils tend to service more affluent communities. The social care means test results in the most affluent communities serving 50% fewer service users per head of population.  Councils serving more affluent communities can spread the jam more thickly.

There are National Eligibility Criteria. But they are meaningless, and given only a false appearance of equity. The belief that eligibility criteria can deliver equity is a myth.

More money without system reform is not the answer. The scale of the post code lottery fatally undermines the sector’s claim that all that is required to solve social care’s problems is more money. There is no discernible difference in outcomes or reputation between the highest and lowest spending councils. It would cost some £8BN if all councils spent at the same rate as the highest spending councils. But ‘more of the same’ would produce no discernible benefit.

The belief that more money – in and of itself and without system reform – is the answer to social care’s ills is a myth.

Personal budgets are not the answer. Personal budgets were introduced as up-front sums of money to empower people to decide their own supports. In the Care Act, however, personal budgets are no more than a financial costing exercise that takes place after all the decisions have been made. Their only material value is to enable the recording of the accumulation of spending over the course of the case which is needed for it to be known when the Care Cap has been reached (if ever the Care Cap is implemented). Whilst Government and the sector jointly proclaimed the Care Act ‘enshrined’ the concept of personal budgets, in reality it buried it.

The belief that personal budgets bring empowerment and choice is yet another myth.

The Care Act is not being delivered. Whilst the Care Act did not introduce up-front allocations, it has provided other key provisions that would indeed enable social care to be authentically liberated by enabling the reversal of the needs-resources polarity. This would place social care on the same footing as the NHS.

However, these provisions are being circumvented by councils. Forensic work is underway in one London Borough that is demonstrating how this is happening.[1] This council is simply conforming to the national template. When councils claim they are delivering the Care Act, what they actually mean is they are describing the ‘same old, same old’ traditional practices in the language of the Care Act. It is another myth.

THE WAY FORWARD – A SYSTEM DRIVEN BY THE VISION OF INDEPENDENT LIVING FOR ALL THROUGH PROPER IMPLEMENTATION OF THE CARE ACT

The Care Act requires all need to be identified against 9 dimensions of wellbeing. The Act’s wellbeing dimensions are fully compatible with the United Nations definition of Independent Living, describing it as people ‘having control over the lives and the decisions affecting their lives’. This is, of course, nothing more and nothing less than has been the promise, yet to be honoured, of successive governments for three decades. The perpetuation of the resource led eligibility needs test is preventing councils from assessing needs for wellbeing against the 9 dimensions. It is simply not happening.

Independent Living, as defined by the UN, should become the standard of wellbeing all people in need of care and support should expect and their needs assessed accordingly.

When assessing needs in this way, it will become possible to enact another long held promise, also provided for in the Care Act but not yet honoured. This is to empower people to have control over their own assessment and support plan.

Councils must accept the person’s own view of their needs and support requirements subject only to their view making best use of resources to bring about independent living for them.

It is self-evident, within a budgeted system, that Councils would have to be able to be honest if their resources are not able to meet all needs assessed for wellbeing identified in this way. The Care Act has created the provisions to make this possible. Above a floor, or minimum guarantee, councils would be free to say what needs they can afford to meet and which they cannot. These provisions are superfluous under the current system whereby only needs that are a legal duty to meet are met.

Councils must be required to make case by case decisions about what needs they can afford to meet to control spending to replace the practice of case by case decisions about ‘eligibility’ to do so

Councils must report on the levels of need and not met. In that way, central and local government can take responsibility to fund social care in the light of full knowledge

These changes will mean;

• The system will know the true cost of enabling all to have the wellbeing they should
• Identifying need against the aspirational vision of independent living will rid the system of the depressing and debilitating effect of the resource led, eligibility needs test. Councils will be able to secure the best possible value from whatever money is made available.

• Authentic equity will be achievable through the equitable allocation of resources informed by levels of needs met and not met.

These changes can be made without new primary legislation. They will require only changes to Government strategy as expressed through the Statutory Guidance to the Act. However, the scale of the change to the service cannot be under-estimated. Local authorities will need to be thoroughly overhauled and re-purposed.

NHS AND SOCIAL CARE

It is disturbing that the Committee is viewing the funding issues in social care through the prism of impact on the NHS before the impact on the older and disabled people who use it. Social care is about so much more than the interface with health. It will be disastrous for both the NHS and social care if the current public wish for social care to be regarded with similar esteem to the NHS translates into the integration of social care into the NHS. The NHS is at its best delivering clinical care to ensure we all have the best possible health of mind and body. It has a lamentable record when it steps outside of that role into providing care. For social care, absorption within the NHS will inevitably result in it being remaining in Cinderella territory.

The way forward that we are proposing will elevate social care. While the NHS enables the best possible health of mind and body social care will come to be seen as the service that enables the best possible wellbeing. While the one enables life for older and disabled people, the other makes life worth living. This will make possible an authentic partnership based on mutual respect and interdependence.

SUMMARY

The current system is highly dysfunctional. Contrary to promises made by successive governments, echoed by claims made by sector leaders that are flatly contradicted by the evidence, it’s a service that routinely disempowers and depresses. These are not the conditions under which to make long term funding decisions.

The way forward we propose involves no financial risk. The only risk is political. Local and national political leaders will be exposed to the true cost of enabling all to have the quality of life they deserve and have long been promised. We don’t believe any self-respecting politician could choose to keep their heads in the sand in the way the current system allows them to do.

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