Why eligibility thresholds are a poor guide to the generosity of the care system

The news that nine out of ten councils exclude people with 'low' or 'moderate' needs from support does not tell the full story on access to care

Source: BBC News

Yesterday, the BBC carried a story about cuts forcing local authorities to limit access to adult social care, based on new figures issued by the Association of Directors of Adult Social Services (Adass). These showed that 89% of councils were formally restricting access to publicly-funded or arranged care to people who had needs that were at least ‘substantial’, under the Prioritising need in the context of Putting People First statutory guidance. They are thereby excluding people with ‘low’ or ‘moderate’ needs from suport.

Given that the equivalent figure was 87% in 2012-13, this does not suggest a great ratcheting up of thresholds since then. However, what we do know is that there was a 5% fall in the number of people receiving publicly arranged care from 2012-13 to 2013-14, and therein lies a truth about the salience of eligibility thresholds.

Research by the well-respected Personal Social Services Research Unit in December 2013 demonstrated that implicit changes to eligibility criteria have played a much greater role than formal changes in thresholds in reducing access to council-arranged care in recent years.

From 2005-06 to 2012-13, the number of people receiving formal packages of care from their council fell by 320,000, found the PSSRU team at the London School of Economics.

The vast majority of the reduction – 281,000 of the 320,000 – happened after 2009-10, when the government’s programme of deficit reduction began.

However, councils tightened formal eligibility criteria more significantly from 2005-06 to 2009-10, when the proportion of authorities setting a ‘substantial’ or ‘critical’ threshold rose from 61% to 80%, than from 2009-10 to 2011-12, when the proportion of ‘substantial’ or ‘critical’ councils rose from 80% to 85%.

Source: Personal Social Services Research Unit, Changes in the pattern of social care provision: 2005/6 to 2012/13

Source: Personal Social Services Research Unit, Changes in the pattern of social care provision: 2005/6 to 2012/13

The size of the reduction in the volume of service users supported by local authorities in recent years appears to be significantly more acute than changes in the local authority eligibility thresholds (see Figure 15). It seems therefore that “implicit” eligibility policies (the interpretation on the ground of the stated local definitions of eligibility thresholds) might have shifted significantly through time without an equivalent reflection in terms of changes in the “explicit” local eligibility thresholds.” (PSSRU, 2013)

None of this is to suggest that the following statements are not true:

  • ‘Substantial’ and, in particular, ‘critical’ thresholds for care restrict access to people in significant need.
  • Councils increase their formal care thresholds in large part to save money.
  • When thresholds increase, significant numbers of people are shut out of the system through the process of reassessing them against the new, higher, threshold.

However, we need to be equally, if not more, concerned about the other factors that shape access to care – social worker judgement and professional discretion; management culture; problems in interpreting the terminology of eligibility criteria; the relative assertiveness of families or, perhaps most significantly, the size of councils’ adult social services budgets. *More positively, it is worth pointing out that reductions in the number of eligible service users should, to some extent, reflect, councils’ efforts to prevent needs escalating through reablement and other initiatives.

This is more important than ever with the Care Act 2014 due to usher in a national minimum eligibility threshold for care – set, so the government hopes, at a level equivalent to the current substantial threshold. The final threshold, due for implementation, will be published in regulations next month, along with statutory guidance on how it should be implemented and practice guidance to support professionals in interpreting the criteria.

The policy ambition is for this threshold to end the “postcode lottery” for care. However, the professional discretion and management decision-making that drives variability in the application of thresholds is not going away. More significantly, with cuts to council budgets set to continue for the next five years, it seems inconceivable that a static, national threshold will end the year-on-year reductions in the numbers accessing council-funded care. That is why we should be careful in seeing eligibility thresholds as our guide to the generosity – or otherwise – of the care system.

*This sentence was added to the article at 12.20pm on 16 September in response to comments made below.

More from Community Care

4 Responses to Why eligibility thresholds are a poor guide to the generosity of the care system

  1. Reablement Rob September 16, 2014 at 10:51 am #

    If I’m reading this article correctly, the research is just saying there were 320,000 less care packages and inferring this is linked to changes in eligibility criteria. However, there were a number of initiatives put in place, particularly from 2009 onwards, to specifically reduce the number of long term care packages required, most notable amongst them was the development of reablement services across the country – perhaps this article is a demonstration that some of these have worked?

  2. Frances Billingham September 16, 2014 at 11:22 am #

    The above article does not take into account the changes within personalisation that allow for universal services to accomodate eligible low and moderate needs that do not require a ‘paid for’ package and may be either comissioned services or community/third sector providers that can service these needs adequately or are services freely abailable in the community in which they live. This allows councils to ensure those with higher eligible needs are funded appropriately.

    • Mithran Samuel
      Mithran Samuel September 16, 2014 at 12:28 pm #

      Thanks Frances and Rob. I’ve amended the article to take account of your points. The point I was trying to make was that the large reductions in the number of eligible service users could not be attributed (in the most post) to tightening of eligibility criteria but in the way eligibility is interpreted, implicit rationing and other factors, some of which I spelt out. However, what I should have said was that some of these factors – such as reablement – are positive in terms of helping people to retain or regain independence and thus not be eligible for ongoing support. That got lost in making the first point about eligibility not being the chief explanation for these changes.

  3. G Hall September 16, 2014 at 4:01 pm #

    I recall seeing a community care article from some time ago that said that in the short term anyway the raising of eligibility criteria did not seem to make very much difference to the services being provided. I think the implication drawn was that Workers were making the criteria work to continue providing similar services.