Colin Slasberg Consultant in Social Care
Peter Beresford visiting Professor University of East Anglia
Last September, spurred into action by what the pandemic told her about the state of social care, Nicola Sturgeon announced an independent review of adult social care to ‘build a service fit for the future’ in Scotland. She invoked the spirit of 1948 for social care to experience the same transformation post Covid as the NHS did post war. The review was led by Derek Feeley, President and Chief Executive of the Institute for Healthcare Improvement.
With remarkable speed, based on extensive public engagement the review has now reported. The headlines are likely to be dominated by calls for a National Care Service. Responsibility for funding will become centralised and new joint Boards with the NHS will be responsible for commissioning and procurement, not the local authorities. The latter will retain delivery of the ‘social work’ function, which means the great majority of current function given the infrastructure required to support and direct the field work role which identifies need and allocates resources to individuals.
Cultural change must precede structural change.
The report’s authors believe that structural change without cultural change does nothing more than re-arrange the furniture. This leads them to the view that it is their first recommendation, which transcends structural concerns to address cultural concerns, that is the real key to delivering what the First Minister wants. The report recommends a system is built from and driven by a ‘human rights approach’, such that ‘Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded’. It would be ‘further enabled by incorporation of human rights conventions’ with particular reference to Independent Living.
Facing up to the resource consequences
It will not, of course, be the first time a review or commission has sought such high minded ideals. Nor would it be the first time a government has signed up to them, but without a serious plan to deliver. What is new in the Scotland review is that it has grappled with how those ideals engage with the question of resources. This raises genuine hope the ideals will for the first time get beyond ‘blue horizon’ managerial pleadings.
The review makes the following three recommendations;
- ‘People should understand better what their rights are to social care and supports, and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
- A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
- Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’
The first two recommendation give practical expression to what a system built to deliver human rights looks like. The third offers a practical way forward to realising it.
The transformation process – from what to what?
The recommendations above also give expression to what a system not built to deliver human rights looks like. Neither the person nor the social worker has any power. Decisions are taken ‘above their heads’. The social worker is rendered merely piggy in the middle. They take information from the individual and give it to the decision maker and then feed the decision maker’s decisions back to the individual. The situation is further damaged by the social worker being ‘hampered’ by having to think first about resources, eligibility and cost.
These first two recommendations make clear that a human rights based approach means that the individual and the social worker must be free to work in authentic partnership to work out the best way to give the individual the best quality of life their circumstances allows without regard to availability of resource.
If these two recommendations were to be delivered, the role of the social worker would be transformed. They will, at long last, be the social care equivalent of the clinician in the NHS. People are generally confident that if they need a diagnosis and treatment from an NHS clinician that the clinician will make their best judgement as to what modern medicine will make possible. Patients are aware, however, they may subsequently have a wait depending on availability of resources.
Managing the resource consequence
For such a positive practice process to ever become a reality in social care, the resource consequences have to be managed. To base a strategy on thinking otherwise, perhaps on the premise that society and their political leaders should fund all the needs of older and disabled people however much it costs, is very high risk. Social care would have to be delivered outside of a budget. Proponents will have to persuade political leaders and the public why social care should have a guarantee of all their responsibilities being funded while no other public service does, not even the NHS. Failure of such a strategy will mean the status quo will not change.
The pragmatic approach is to accept that social care will continue to be delivered within a budget determined by the democratic process, national or local.
The Feeley review addresses this reality in the third recommendation above. If need is to be identified without regard to resource availability, there is no arithmetic prospect that the resources required will coincide with the resources available with the precision required to match spend to budget. The system must allow for need to exceed resource.
The political consequence
The current, eligibility based system does the exact opposite – it does not allow for need to exceed resources. It actually forbids it. The system delivers the imperative to spend within budget by ensuring the flow of needs it meets is determined by the budget. This is made evident in Scotland by the scale of the post code lottery despite all councils ostensibly working to the same eligibility criteria. Because ‘need’ is determined by resources, it is a system that never recognises there is any unmet need. Whatever budget is provided is always enough.
That, of course, is music to the ears of political leaders with other priorities on their minds. But if the Scottish government adopts the recommendations of this report, that comfort will have been given up. Councils will know the true cost of delivering on political leaders’ commitments to the human rights of their older and disabled citizens. The commissioners will have the information to tell them.
Implications for England
We have to wait and see how Holyrood responds. But however it does, perhaps this review’s thinking can influence the debate in England where the same eligibility based system is in place The debate in England has yet to get beyond the funding questions. Absent is any thought of vision. But only with vision can we know what we want for our money. And only with vision can we ensure we are spending our money well, achieving the results we want, and how far we are falling short.
The Scotland review’s third recommendation as above is a remarkably simple idea. Eligibility of need must be replaced with affordability of need to control spending. Those responsible for the system will need to be prepared for transparency and honesty about any gap between needs and resources. Unmet need in social care should replicate the functions waiting times have in the NHS. Firstly they are a ‘safety valve’ at the front line when resources lag behind need. Secondly they act as a weather vane so political leaders know what way the wind is blowing when the time comes round to make political decisions about the funding requirements for social care.
The Scottish review recommendations resonate powerfully with the view about the transformation change required in England set out by Barry Rawlings, leader of the Labour opposition in Barnet. Barry’s blog places the agenda in the English context.
Whether or not the Scottish government lights this beacon, hopefully leaders in England will open their minds to the possibilities opened up.