TWO CONTRASTING CAMPAIGNS FOR REFORM OF SOCIAL CARE – SECTOR LEADERS AND DISABLED PEOPLE

The Local Government Association has released a statement that 91% of 600 councillors support a campaign for reform of social care launched by a partnership called Social Care Futures. As part of re-building society post-pandemic, their campaign calls for social care to serve the purpose of enabling people in need of care and support to: ‘live in the place we call home, be with the people and things that we love, in communities where we care about and support each other, doing the things that matter to us’.
This is a warming vision whose worthiness few will dispute. But before committing to it political leaders are likely to want to know the cost. The Chancellor will certainly want to know the cost before his colleagues commit. However, with this vision so different from the current realities of social care, testified by the 500 people who responded to a survey by Social Care Futures, the cost is simply not known. All that Social Care Futures can say is;‘Government resources must be increased to the level that allows people the funding they need to live a life like other people’.

Social care has not lacked for a vision similar to this for a long time. The most recent is a vision based on wellbeing in the Care Act of 2014. Before that the ‘personalisation’ agenda of the noughties. Neither have happened, with sector leaders claiming lack of funding.
But there is a chicken and egg situation. While social care leaders say they cannot deliver a visionary service without more money, in the absence of the vision being costed, political leaders will not give sector leaders more money. It is an impasse.

Breaking the impasse – a parallel campaign
Coincidentally there is another campaign to reform social care concurrently being launched. It has been developed by a national collaboration of disabled peoples’ organisations. Included in its proposals is a route to break the impasse. It comes in the form of endorsement of the principle of ‘progressive realisation’ of the resources required through ‘concrete action’. This is a concept taken from the United Nations vision of Independent Living, which is a vision almost identical to Social Care Futures’ vision. The UN recognises that the resources required for people to lead the lives right for them is a political matter, not a legal right. Much as we may like the world to stop still while social care gets the funding it requires first, it is most unlikely political leaders will be so moved by the Social Care Futures vision that that will happen. The concrete action that must be taken is the key.

Concrete action
The action required to make progressive realisation a reality relates back to the very reason why social care leaders do not know how much it would cost to give people the lives they should have. In the NHS, clinicians diagnose and recommend treatments based on what they see before them. Waiting lists act as the financial safety valve if clinical need outstrips resources at the operational level, and as the weather vane and information source for funding requirements at the strategic level.
This is not so in social care. Resources determine what is recognised as ‘need’. Managers determine ‘eligibility’ thresholds in order to ensure demand matches the local budget. It is the reason why sector leaders have no idea how much it would cost to resource the Social Care Futures vision or any other vision.

The action required is to abolish the resource led definition of need – the eligibility process. Councils must require their front line practitioners to identify and cost all the needs each individual has to live the life described by whatever vision is adopted. On a case by case basis, councils must decide what can be afforded and what cannot. The needs unmet must be aggregated and put in the public domain. In this way, unmet needs in social care can sit alongside waiting lists in the NHS to inform future budgets. This is an approach that has recently been adopted by the Equality and Human Rights Commission (please see link below). It recommends the Secretary of State should periodically set out plans to close the gap between needs and funding.

Delivering change – problems for Social Care Futures
At the core of the action required is the axis between needs on the one hand and resources on the other. A founding principle of the NHS was that need must precede resources. In social care, from the outset, the opposite applied. The concrete action required is to reverse the polarity putting social care on the same basis as the NHS. Whilst simple in concept, it will require a change in the both the culture and modus operandi of the way councils deliver their part of the social care system that will shake the system to its roots. But this creates a problem for Social Care Futures. It is a partnership involving the key leaders of the sector – the LGA, the Association of Directors of Social Services, Skills for Care, Social Care Institute of Excellence. But the sector consistently and collectively denies the need for change in the way councils operate, citing only lack of funding as preventing them from delivering the personalisation vision.

But the evidence not only undermines this position, it points to a seriously dysfunctional system;
• In 2009/10 (at 2019/20 prices) £21.4BN was spent on social care, which included £1.3BN of NHS money. In 2019/20, £22.4BN was spent, which included £2.3BN of NHS money. Spending in real terms has thus actually increased by about 5%.
• Whilst sector leaders point to increased demand from increased demography thus suggesting an effectively cut, they are silent on levels to which demand has – or should have been – reduced.
• One of the selling points of the personalisation agenda was that it would reduce demand. By matching resources to the personalised needs of individuals, better outcomes at lower cost would follow.
• Over the past decade the sector has proclaimed great success in delivering a range of demand reduction strategies. Chief amongst them has been what is called ‘strengths based practice’, designed to eliminate the dependency on services. However, while all councils have adopted the practice, sector leaders offer no information as to how much this may have saved.
• In 2009/10, 1.7 million people were served. In 2019/20 that had reduced to 1.1 million. Spend per service user has therefore increased by some 35%. Why does the Social Care Futures survey find people seriously under-supported?
• According to the LGA’s own figures, shared confidentially with councils but not released to the public, the highest centile of councils spent 60% more than the lowest in 2018/19. However, there is no suggestion that the highest spending councils have broken the mould any more or any less than the lowest.

These figures point to a dysfunctional system. Until and unless sector leaders acknowledge as much and the parts they have played in its design and delivery, they will remain a central part of the problem, not the solution.

Conclusion
The immediate needs for increased funding within the existing system are beyond dispute. In particular the low level of pay for the care workforce and the unfairness of the charging regime and pricing that risks market collapse should be addressed without delay. However, hopes for funding levels beyond the immediate that rest on the belief that government will be so moved by a new vision that it will commit regardless of cost is at best naïve. Worse, how can government have the confidence required to entrust new funds to a sector so dysfunctional and incapable of making best use of the resource it already has.
It is easy to sign up to Social Care Futures’ vision. Who wouldn’t? But if we want a system of social care driven by that vision, or any variation of it, it will only happen if government listens more to the call for the fundamental systemic change that the disabled peoples’ movement includes in its agenda for change.

1. https://www.equalityhumanrights.com/en/inquiries-and-investigations/inquiry-challenging-decisions-about-adult-social-care