Government bids to shift care eligibility criteria to focus on outcomes not deficits

Initial proposals for national minimum eligibility threshold revised after council chiefs criticised them as being based on 'outdated' deficit model of care

Social worker and client
Photo posed by models (Credit: Rex/Burger/Phanie)

The government is seeking views on how eligibility criteria for care can be reshaped to focus on helping people achieve desired outcomes, rather than on addressing their perceived deficits.

In future, eligibility could be focused on helping people maintain good personal hygiene or live comfortably in their home, rather than on supporting them to carry out tasks they are unable to do, such as toileting.

The Department of Health has already revised proposals for its national minimum eligibility threshold for care to promote a greater focus on outcomes in eligibility decisions, after council chiefs said initial plans were “outdated”.

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These revised plans were issued today as part of a wider suite of draft regulations and statutory guidance under the Care Act 2014, issued for consultation. However, one of the issues the DH is seeking views on in consultation is whether to go further in enshrining an outcomes focus in the national minimum eligibility threshold.

The initial proposals, issued last year, had stated that people would have eligible needs for care and support if they had a mental or physical impairment or illness and faced significant risks to their wellbeing as a result of issues including not being able to carry out one or more personal care or household activities.

Similar to FACS

This was not unlike the current Fair Access to Care Services (FACS) guidance on eligibility, which bases thresholds on the risks to people’s independence and wellbeing from their inability to carry out personal care tasks or sustain social roles.

The initial proposals were described as “outdated” in being based on a deficit model of care that focused on what people were unable to do, said the Association of Directors of Adult Social Services and Local Government Association in a joint response to the plans.

To take account of these criticisms, the DH has redrafted the proposals so that people who are disabled or ill are deemed eligible for care if they are unable to achieve certain outcomes, with a consequent significant impact on their wellbeing.

However, the criteria issued today are described in similar terms to the initial proposals. For example, the proposed outcomes people should be supported to achieve include “carrying out some or all basic care activities”, such as eating and drinking or toileting.

“Using a list of activities or tasks in this way risks undermining the focus on outcomes which is espoused by the [Care Act 2014] in other areas, and we would like to consider alternative approaches during consultation,” said the DH.  “If we were to redefine these basic care activities as outcomes, the following might be an example of the sorts of concepts that could be used: managing/maintaining nutrition for good health; maintaining personal hygiene and everyday appearance; living comfortably and safely at home; cleaning and maintaining one’s home.”

A higher threshold?

The wording of the criteria suggest the threshold proposed today is higher than that put forward last year. Notably, whereas today’s criteria state that eligibility should be based on people’s inability to carry out “some or all basic care activities”, last year’s proposals stated based eligibility on an inability to carry out “one or more basic personal care activities”.

This point was picked up by Age UK in its response to today’s proposals.

“The regulations are written in such a way that we worry that people with dementia who need help to continue to live at home with dignity could be screened out, together with those who struggle with dressing, or washing, or going to the toilet or preparing food: from now on the inability to do just one of these fundamental things will not be enough to qualify you for support and Age UK’s concern is that without it, some older people’s needs will escalate, undermining their capacity to continue to live at home,” said Age UK’s charity director, Caroline Abrahams.

The government is allocating no less money – about £25m a year – to the national minimum eligibility threshold than it had planned to do so previously; rather. But it may have revised the threshold upwards to reflect its policy objective of establishing criteria equivalent to the ‘substantial’ band under FACS used by almost 90% of local authorities. FACS refers to people covered by the ‘substantial’ band as being unable to carry out “the majority of personal care or domestic routines”.

Last year’s initial proposals had been criticised by Adass and the LGA as setting a lower threshold than ‘substantial’, leaving councils underfunded to implement it.

Charities warn criteria will exclude many from support

Charities by contrast have argued for a ‘moderate’ equivalent threshold to be implemented and many joined Age UK in warning that today’s proposals would exclude many people in need of support.

“The government has passed up the chance to drive through a genuinely preventative system,” said Richard Hawkes, chief executive of disability charity Scope and chair of the Care and Support Alliance (CSA) of 75 charities, provider organisations and service user bodies.

He added: “It has instead hardwired the year-on-year rationing that’s seen people squeezed out of the system. Without that help people’s lives fall apart. This will also place unbearable pressure on family carers.”

Research for the CSA last year revealed that a further 260,000 older and disabled people would have received care and support from their council in 2010-11 had a ‘moderate’ threshold under FACS been in place across the country.

The Royal National Institute for the Blind (RNIB) raised concerns that blind people would be particularly badly hit by today’s proposals in the light of evidence it produced last year that there had been a 43% fall in the number of visually impaired people accessing care in England from 2005-13.

“Research from RNIB in 2013 showed a steep decline in the numbers of blind people receiving necessary care services; the proposed eligibility criteria will accelerate this,” said Fazilet Hadi, the charity head of inclusive society. “They don’t recognise sensory loss as a distinct disability, and fail to recognise the support needed by people with sight loss to do everyday tasks.

Respond to the consultation

The consultation on the draft eligibility criteria and other regulations and statutory guidance runs until 15 August. Practitioners can respond by emailing careactconsultation@dh.gsi.gov.uk

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