The White Paper says social care must give people ‘choice, control, and support to live independent lives’ through ‘outstanding quality and tailored care and support’ which they must find ‘fair and accessible’. No one will argue with any of that. If achieved, most will agree that the Prime Minister’s promise to ‘fix social care’ had been delivered.
But there is a problem. This vision is no different from the vision set out when the personalisation strategy was launched in 2007. Nor is the vision any different from a re-launch in 2011 by Think Local Act Personal (TLAP), the body entrusted by Government to progress the personalisation strategy. TLAP gave it the title ‘Making It Real’ – the ‘it’, we may believe, being personalisation – making the implicit assumption clear that personalisation had not happened. And when the first iteration of ‘Making It Real’ failed to make it real, the strategy was re-launched in 2018.
So the White Paper represents, incredibly, the fourth launch of a strategy with a 14 year history of repeated failure.
Government shows no curiosity as to why the personalisation strategy has failed. There are three key elements of the strategy – direct payments and personal budgets, empowerment of people with information to navigate the system and exhortations to councils and their staff to change their behaviour. Each has proven problematic.
Direct payments and personal budgets
The White Paper sees these two mechanisms as a ‘vital way in which people can have more choice and control over their care and wellbeing’. However, meaningful personal budgets do not and cannot actually exist while it has been known for twenty years that direct payments work only for the small minority evidenced to be able to manage their own support systems in a harsh environment.
The original idea of personal budgets was as an entitlement to a ‘fair allocation’ of money ‘up-front’, sufficient for the person to purchase the supports that would give them ‘full citizenship’. The New Labour government was enthusiastic, but before implementation, dealt it two blows that were fatal.
The first blow was in changing the idea of a ‘fair allocation’ to be just a fair allocation of whatever budget the local council happened to have.
The second and final blow was to declare that the ‘up-front’ allocation was not an entitlement, just an ‘indicative’ amount. What people actually got would be known once the council had decided what needs it would meet and with what resources.
These two blows killed personal budgets at birth. The Care Act of 2014 introduced the term ‘personal budget’. But it could not be clearer that it was nothing more than an administrative costing exercise taking place at the very end of the process. A ‘personal budget’ under the Care Act is not a budget in any meaningful sense of the word. It is in reality a completely pointless exercise.
It is an extraordinary act of manipulation of the public’s mind that personal budgets are even seen to exist, let alone have a transformative impact. A key part of that achievement was to conflate personal budgets with direct payments as if they were the same. But they are completely different. When direct payments were introduced in the 1990’s they allowed disabled people to step outside the mainstream provision to employ their own Personal Assistants and so control their support. It worked then and it still does. Up-front allocations, however, played no part then and play no part now. But by showcasing the successes of the small number of people self managing with a direct payment – about 8% of all long term service users – and parading them under the banner of being a form of ‘personal budgets’ TLAP has been able to keep the personal budget mythology alive.
Empowering people to navigate the system
The White Paper says people ‘struggle to understand the system’. This state of affairs is fundamentally disempowering. Yet provision of information as a means to empowerment was a key part of the personalisation strategy from the very beginning. Why have councils failed over so many years in what is surely a very simple task?This invites further hard questions. Do councils actually want to empower service users? Will empowering service users actually impede their operations? Or is the system so complex and obscure that it is not even navigable?
So far Government has not shown sufficient curiosity to investigate the issue. Instead it has committed a modest £5M to ‘pilot and evaluate new ways to provide personalised advice to help people navigate local adult social care systems’. What point is there in such work without first answering the obvious unresolved questions?
Exhortations to change
The White Paper is packed with promises to change the behaviour of councils and their staff – to be person centred, to be empowering. They are the same promises made in each of the previous three launches of the personalisation strategy. Indeed, with only minor changes to the wording, the exact same promises can be traced back even further to the Community Care reforms of the early 1990’s.
Yet, again, Government shows absolutely no curiosity as to why these positive behaviours, which councils readily sign up to, have not happened. The hard question neither central nor local government seem to ask is whether there is something about the system that is conditioning the disempowering, resource-led behaviour of councils and their staff? If there is, unless it is addressed, the promises are not worth the breath required to speak them.
The Care Act
The White Paper is, however, surely right when it says the 2014 Care Act ‘particularly its focus on wellbeing, provides a strong foundation for our vision’. The problem is that it then picks out five features of the Act but completely misses out the two most critical to delivery of the Act’s vision. The Act places specific duties on councils to;
1. identify all needs a person has for their wellbeing, which can have no regard to resource availability
2. have regard to the need to ensure that sufficient services are available for meeting the needs for care and support in their areas
Neither of these requirements are being delivered. The second, indeed, cannot be delivered without the first. And the first is not delivered because Government policy is to maintain the traditional system whereby a need is a need only if there is resource to meet it.
This is the effect of the ‘eligibility’ system. Councils calibrate what they deem to be a ‘need’ calling for council resources to that for which they have resource. Anything else is simply a non-need, a mere want or wish, but not a need. This circular, resource-led way of defining ‘need’ explains why there is a 60% disparity in how much support different councils give their service users. It also explains why councils never have any information about unmet need.
Eligibility operates covertly. Councils tell their public that they follow the national criteria. These say that all needs that are ‘important to the person’ due to having a ‘significant impact on their wellbeing’ are treated as ‘eligible’. This is, of course, hopelessly undeliverable. No council could afford it. The real eligibility decisions are made behind closed doors.
And, of course, it requires a process that destroys any prospect of being person centred or empowering. People have to be fitted into whatever types of needs their council will consider ‘eligible’, cutting across the uniqueness of need upon which the notion of being person-centred rests. And only the professionals are allowed to work out if there is a ‘need’, cutting across any notion of people having any control over the way their needs are defined.
Two systems of social care
There are two version of social care in this country – the official, glossy brochure version and the real one. They are worlds apart. Most people only find out when they have to seek help. The glossy brochures dupe the public into believing all needs important to each person’s wellbeing will be met, that personal budgets give people control and empower them, that national eligibility criteria ensure equity and fairness, that decisions are made in an open and transparent way. In the real world there is gross inequity, decisions are made behind closed doors, budgets, not importance to the person, determine priority and many hundreds of thousands of people with support needs go unhelped. Of course people find the system unnavigable. It is a complex web of false leads, mixed messages and downright untruths. It has to be that way if central and local government are to maintain that their glossy brochures tell the truth.
Prospects for change
The White Paper introduces some changes that will be broadly welcomed. The reduced severity of the means test, some attention to the workforce and a kick start to more housing options. But these are peripheral to the core challenge the White Paper itself identifies – the need for a system that empowers the individual to create personalised support. Yes, there are pockets of excellent practice dotted around the country. But that is no different from how it was in 1986 when the Audit Commission found, in a sea of mediocrity, ‘champions of change’. With exceptional drive and imagination, they were people and organisations that performed well despite the system or by by-passing the system. But their work has never been scaled up, and when the ‘champions’ went, their work usually went with them.
It is either a great irony, or an act of great hypocrisy, that the Government is promising visionary change whilst clinging to the system that guarantees it can never be realised. The Government shows zero appetite for real change. Why should it? It’s a system that allows them to spend as much or as little on social care as they choose, and the system will deliver. The system is constitutionally built not to overspend whilst always meeting its statutory responsibilities. There is never the inconvenience of unmet need. It has allies in Think Local Act Personal who supply a steady stream of material for the glossy brochures. It is politically low risk.
The White Paper is right in saying the legislation is in place. However, we await political leadership that has the strength and integrity to implement it in full. It will not actually cost a penny more to do so. But it will require political leaders to not only talk big but who act big. Political leaders must allow the professionals to work in authentic partnership with service users to identify and cost all the needs for wellbeing of every individual in need of care and support. They should set a standard for wellbeing. The United Nations* definition of Independent Living has international credibility and is an obvious candidate. They must then be big enough to hear how much money they must find if all are to have the level of wellbeing political leaders have said they want for them. And they must have the integrity to accept with good grace that their commitment to the wellbeing of people in need of care and support will be transparently tested. It will be measured by the action they take and at what pace to close the gap that will have been exposed between needs and resources.