Can social care contribute to health’s preventive agenda?

When Gordon Brown announced an initiative to promote new preventive services in the NHS earlier this month, the social care profession may have been forgiven some cynicism. The prime minister promised patient screening for early signs of stroke, heart and kidney disease under the heading ‘prevention is better than cure’.

A similar approach was promoted in adult social care in the government’s green paper ‘Independence, Wellbeing and Choice‘, which described how there should be “a greater focus on preventive services to allow for early, targeted interventions”.

The following white paper, ‘Our Health, Our Care, Our Say‘ confirmed this approach: “We must re-orientate our health and social care services to focus together on prevention and health promotion. This means a shift in the centre of gravity of spending.”

However, the whole issue of preventive services in social care is now being over-shadowed by disputes about eligibility criteria for services amid serious funding shortfalls. Just before Christmas, the London Borough of Harrow was found by the high court not to have given ‘due regard’ to the Disability Discrimination Act 2005 (DDA) when it decided to limit adult care services to those in ‘critical’ need only, raising the bar from a ‘substantial’ need threshold.

The case brought by legal charity the Public Law Project on behalf of three residents with ‘substantial needs’ also challenged the council’s decision on the grounds of a flawed consultation and breach of the Human Rights Act 1998, but the court rejected these claims.

Louise Whitfield, project solicitor with the Public Law Project, says the council’s decision was certain to breach the DDA, and if the authority persisted with the same approach there might be another legal challenge.

Three other councils have already adopted a ‘critical’ banding – West Berkshire, Wokingham and Northumberland, although the north east authority is considering lowering this to a ‘substantial’ grade.

The number of authorities in the critical category is set to rise. Statistics from the Commission for Social Care Inspection, released in November, showed that three-quarters of councils are now planning to adopt a ‘substantial’ or ‘critical’ threshold by the end of this financial year, which has risen from 62% in 2006-7.

When the eligibility criteria bands were enacted in 2003 under Fair Access to Care guidance, there was acknowledgement from the Department of Health that the bands would be set according to local authority budgets.

Tighter budgets

So the scene was set for more structured eligibility decisions based on funding levels, and while the government has poured resources into the NHS, the story in social care has been different. A Counsel and Care report out this month revealed that there is a shortfall in funding of, on average, £25,000 in the care of each disabled person over 65.

Government financing of social care, which was restricted to a 1% increase in last year’s comprehensive spending review, combined with capping on council tax rises, has certainly had an impact, with many local authorities forced to tighten their belts.

These significant financial pressures are undoubtedly having an increasing effect on the nature and level of social care provision.

Former social services director Ray Jones says: “Funding is driving this. No one wants to rationalise services.”

He believes there should be a “national entitlement” to care and a public debate on the level of investment in social care by the government. Jones carried out a management review into the case of Steven Hoskin, a man with learning disabilities who was murdered in St Austell after he cancelled the help he was receiving from Cornwall Council’s social services. Jones found that a risk assessment was not carried out on Hoskin after he said he no longer wanted to receive services.

Refused service

Carol Tozer, Cornwall’s director of adult social care, says she shares people’s concerns about the tightening of eligibility criteria, but says this was not a significant factor in Hoskin’s case.

“It is a bit of a red herring because he refused the service a year prior to his murder,” she says, “and he was empowered to make decisions – he had held down job placements.”

The council has now adopted a medium term financial strategy that should protect it from the need to move to a critical banding from its current level of substantial – a move that would remove support from 1,200 people – even though it is now facing “unprecedented levels of need”, Tozer says.

She welcomes the forthcoming green paper on social care funding, which could take up some of the recommendations from the King’s Fund report by Sir Derek Wanless about a move away from means-tested care.

“We need to be able to deliver the promise that was in Our Health, Our Care, Our Say that has gone quiet,” she says. “There should be a 5% move of resources from acute to social care.”

Meanwhile, Tozer says Cornwall is funding the voluntary sector to help ensure important preventive services are provided.

John Bolton, the Department of Health’s new strategic finance director for social care, believes the sector needs to think hard about which preventive services are effective and concentrate on those.

“We need to look at the evidence of where interventions can make a difference. Intermediate care is the best example of a service that does this,” he says.

In Wokingham, which will be operating a critical banding from February this year, good preventive services are key to the approach of adult social care. Pat Brecknock, the council’s corporate head of community care, says the authority has made stringent checks to ensure it will not breach any if its statutory responsibilities by adopting a critical criteria, and that no service user will have to move home as a result of the policy change.

“We have been able to invest in some new preventive services to support people who in the past had statutory services but in the future won’t,” she says.

Drop-in groups for people who used to attend a day centre are being developed, where people can join in a collective activity support services to help people maintain their tenancies are also being bolstered.

The move to a critical banding was necessary, Brecknock says, because the council’s adult care budget was under huge strain. “We are the lowest funded unitary authority in England, and we have the highest growth rate of older people in the south east,” she says.

“We have contained the growth in our budget and are still able to spend more on services,” she says. She predicts other councils will have to follow suit.

These developments are a cause of great stress for social care professionals who have no control over them. A recent Community Care survey of more than 300 professionals revealed that more than half were under pressure to reassess clients as no longer eligible, and a third would be prepared to exaggerate a client’s needs to ensure they meet the eligibility criteria for services.

Social workers have always had to make difficult decisions when it comes to their clients, but the pressure on them is growing as eligibility criteria is being tightened, with few exceptions, across the country.

So what happens next? Well, the promised green paper may change the funding landscape, but with national resource increases continuing to be sluggish, social care provision will come under ever greater strain.

Demand for adult social care is set to increase at an alarming rate as the older population grows much larger. The need to ration services will become more pressing and force politicians and professionals to make harder choices about where to divert their resources.

Preventive services cost money and while the NHS may be given the cash it needs to deliver, will social care receive similar backing? Until it becomes politically necessary to do so, and it helps to revive a struggling prime minister’s fortunes, then it looks unlikely in the near future.

Related articles

‘People with a similar level of need to Steven Hoskin would not receive services now’

Cornwall missed chances to prevent Hoskin’s death

Further information

A Charter for Change