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

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

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.