Andrew Dilnot’s proposals for adult care could see social workers undertaking an increasing number of assessments, reports Mithran Samuel
If the government implements the Dilnot commission’s proposals, the landscape of community care assessments and eligibility is set to change dramatically.
Instead of variations in social care eligibility between councils that exist under the current Fair Access to Care Services (FACS) framework, there would be a single national threshold.
Service users would no longer face losing access to care when they move, because the councils whose areas they were relocating to would be under a duty to fund their entitlement to care, pending a reassessment.
Users would also have a better understanding of their entitlements to care through a more “objective”, simple assessment and eligibility process that made clear why people are, and are not, eligible.
And the volume of assessments carried out by care professionals would increase.
Entitlement to assessments
While all people who appear to have a care need currently have an entitlement to an assessment, many self-funders do not receive one. Instead they are nudged out of the system by councils assessing their means first, and then denying them a needs assessment.
Under Dilnot’s plans, all people with eligible needs would be entitled to state funding after they had passed a cap on their costs of up to £35,000.
Councils would have to assess and assign “notional care packages” to self-funders so that their care costs could be calculated to identify when they would reach the cap.
Reflecting this, Dilnot has put the extra costs of his assessment proposals at £200m a year, or over £1m a year per local authority.
He says that a system of assessment and eligibility should be implemented first under the existing FACS framework with a national threshold at the “substantial” band. This should be followed by the production of a revised, more “objective” framework.
So what should this look like?
Criticisms of FACS are legion, but a key problem concerns its apparent incompatibility with personalisation.
FACS’s approach on standardising service users into particular categories of need is at odds with personalisation’s emphasis on responding to people’s individual circumstances, found a Commission for Social Care Inspection review of FACS commissioned by the last government.
Resource allocation system
One element of personalisation that FACS is clearly in tension with is the resource allocation system. Often, professionals quantify people’s needs against a RAS questionnaire, generating an indicative personal budget, and then revise this budget downwards to ensure that only eligible needs are funded.
Social care consultant Andrew Tyson says councils often spend a lot of time attempting to reconcile FACS with their RAS. He suggests doing away with FACS and simply assessing people through a RAS, saying this would meet Dilnot’s tests of objectivity and transparency.
“A fundamental starting point for an RAS is that it should be simple and in the public domain, so there’s a degree of public accountability,” he says.
Councils should make their RAS questionnaire available on their websites and give service users an idea of what they would get in a personal budget, based on a self-assessment carried out online, he says.
Health and social care consultant Melanie Henwood, who conducted research for the CSCI on FACS, suggests this approach could work: “The clarity and transparency is certainly there with RAS,” she says.
Ethic of personalisation
Social worker Kathryn Simmons (not her real name) says the ethic of personalisation should be at the heart of any replacement for FACS: “The more there is the ability to escape from lists and criteria and assess needs and circumstances in a social context rather than listing what someone can and can’t do, the better,” says Simmons, who works in older people’s mental health.
She raises a warning, however, about Dilnot’s emphasis on objectivity, pointing out that this was a central aim of FACS: “My concern is that a new ‘objective’ assessment and eligibility system would suffer from the same faults, in that there would still be differences in interpretation and mostly what would change would be a further layer of tick boxes and forms to complete.”
Henwood says that there are problems with reconciling two of Dilnot’s goals: that of clearly defining who should be and should not be eligible (objectivity) and making any framework easy for the public to understand. “Objectivity implies the use of a specific methodology or detailed criteria, but as soon as these begin to be elaborated, maintaining simplicity and clarity tends to become more problematic,” she says.
Henwood adds that any reformed assessment and eligibility system would have to reconcile another tension, between councils’ two roles in assessment: identifying need and rationing resources.
One possible way of tackling this, she suggests, is for assessments to be commissioned out by councils, to ensure the independence of identifying need from resource considerations. “There are various organisations that have developed their own approaches to assessment,” she says. “User-led organisations and the third sector have got a lot of strengths in this area. Self-assessments have to be at the core of this.”
But where would this leave social workers and other care professionals?
She suggests more independent social work roles could be on the cards. “There are opportunities here for social work. Maybe there will be the development of independent social work roles and that gets round the tension of the duality of councils’ roles.”
Any opportunities for social workers are likely to depend on the higher volumes of assessments under Dilnot being matched by sufficient resources, to ensure caseloads do not become unmanageably high. And that depends on the government’s response to Dilnot, due in next spring’s white paper.
‘Framework is confusing and jargonistic’
It’s not clear or transparent for the people using the system. People don’t know what their rights are.” This comment from social worker Trudy Burns (pictured) on the Fair Access to Care Services framework explains why the Dilnot commission called for it to be scrapped.
Burns, who works in East Sussex Council’s community learning disability team, says service users and families struggle to understand FACS.
“It’s quite jargonistic,” she says. “We’re quite good in East Sussex – we make things easy to read and accessible – but unless you are trained and within that system it’s very difficult to know what you will be entitled to.”
FACS embodies a limited view of social work, says Burns, who is one of the College of Social Work’s spokespeople. “It’s hard to advocate for people when you’re thinking just about the eligibility criteria. There’s more to an individual than whether they are eligible.”
She feels one of her key roles is signposting people to services and organisations that can meet needs deemed ineligible by the council, a skill underplayed by FACS.
She adds: “Social workers have moved away from giving advice on anything outside the services that local authorities offer but I don’t think that’s where the profession should be.”
She says professional judgement should be at the heart of any replacement for FACS, but there cannot be too much room for interpretation, to ensure service users know where they stand.
“I think the new framework envisaged under the Dilnot proposals would need to have sufficient detail for people to understand where they fit in. Perhaps case studies and examples will help. With less detail it’s open to interpretation.”
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