How eligibility criteria should inform social work practice with adults

Recent research

There is surprisingly little research about how social workers actually operate the eligibility criteria, particularly across different service user groups. A contributor to Cutting the Cake Fairly (Commission for Social Care Inspection, 2008) noted that “the four bands [critical, substantial, moderate and low] are open to massive interpretation…they lay claim to an objectivity that is not present” (p34).

A recent survey on the use of FACS criteria (Fernandez & Snell, 2012) notes that “there is very little evidence about how these bandings are applied” and what were the defining characteristics of service users in each category. They found that applying the criteria was seen as a highly subjective process (p53) with a “lack of certainty”. There was also a correlation between eligibility policies and bandings, in that workers in authorities with tighter eligibility policies were more likely to assign a higher banding to cases, which could mean that needs were being “up rated” (p23). 

They also found a very wide range of responses to the case studies used in the research, where judgements made about a particular situation spanned all four eligibility categories, which is obviously very concerning in practice. Meanwhile, Slasberg (2011) provides an interesting breakdown of some of the problems inherent in the actual wording of the bandings – the definition of the word “vital”, for example, is open to wide interpretation.

Charles and Manthorpe (2007) looked at the impact of FACS on a team working with older visually impaired people. They highlighted its ambiguity; a lack of training for practitioners, and the use of ‘professional discretion’ in their assessments, meant that wherever the bar was set, assessments would show that the service user met those criteria. It is hard to condemn this motivation of social workers “behaving in practice as ‘knights”, motivated by their professional ethic and desire to do their best for their clients’ (p154), but it may exacerbate perceptions and problems of inequity across service use groups and between service users. Interestingly, practitioners in this study were “unanimous that FACS had not made much, if any, difference to their assessment practice” (p149).

A study by Cestari et al in 2006 looked at the operation of FACS in mental health teams, which they summarised as having “revealed and reinforced a growing separation rather than integration” (p480) of such joint teams. They found lack of training was again a problem and raised particular difficulties in a multi-disciplinary team. They also noted the potential for “gaming, raising the threshold beyond the level indicated by the assessment” (p479). On a more positive note, though, they found FACS could offer a more systematic, less arbitrary way of assessing people which could help in giving explanations to service users.

Newton and Browne (2008) looked at the application of FACS in older people’s teams, and again found interviewees “using their professional judgement to decide that the needs are just above the threshold, wherever the authority has drawn that line!” (p243). Slasberg (2011) notes that tightening eligibility thresholds has been demonstrated to make very little impact on local authority spending.

The government is now looking at revising the eligibility framework as part of plans to introduce a national minimum threshold (Department of Health, 2012). Whether the fairness of Fair Access to Care will improve remains to be seen.

Impact on practice

• Social workers should sit down in their teams and compare how they are making decisions about FACS eligibility, perhaps by looking at a case in a team meeting and discussing how they would apply FACS.
  
• It is also important that all members of multi-disciplinary teams understand the requirements of FACS, so joint training and/or updates on a team’s application of FACS might be necessary.

Questions for practitioners

• Have you received training about how your authority applies FACS, and has this been updated? If not, could you ask for some refresher training?
  
• In your work with service users and carers, do you explicitly discuss the FACS framework in order to make it clear how decisions are made? If you can both work together to understand and address FACS, the potential for service users to feel they have been treated unfairly or irrationally can be diminished.

References and further reading

Cestari. L., Munroe, M., Evans, S., Smith, A., & Huxley, P. (2006), ‘Fair Access to Care Services (FACS): Implementation in the mental health context of the UK’,  Health & Social Care in the Community, 14(6), p474-481
Charles, N. & Manthorpe, J. (2007), ‘FACS or fiction? The impact of the policy Fair Access to Care Services on social care assessments of older visually impaired people’, Practice: Social Work in Action, 19(2), p143-157.
Commission for Social Care Inspection (2008), Cutting the Cake Fairly: CSCI Review of Eligibility Criteria for Social Care, London: Commission for Social Care Inspection
Department of Health (2012), Caring for our Future
Fernandez, J. & Snell, T. (2012), Survey of Fair Access to Care Services (FACS) Assessment Criteria Among Local Authorities in England, PSSRU Discussion Paper 2825, Economics of Social and Health Care Research Unit
Newton, J. & Browne, L. (2008), ‘How Fair is Fair Access to Care?’, Practice: Social Work in Action, 20(4), p235-249.
Slasberg, C. (2011), ‘Towards a new eligibility framework that serves the interests of both service users and councils’, Research, Policy and Planning, 29(1), p45-59.