Cuts and reform – the Cameron legacy for adult social care

On coming into power in 2010, the then coalition government commenced two agendas for adult social care, one of reform and one of retrenchment, the conflicts between which have lasted to this day.

Reform came in two parts. One concerned the modernisation and consolidation of the then very complex and outdated law around adult social care through a project led by the Law Commission and initiated under the previous Labour government.

The other concerned reforming the funding of adult social care to achieve a better balance of costs between the state and individuals and help people protect their assets, notably their home – a key objective of the 2010 Conservative Party manifesto. This work was entrusted to a commission led by economist Andrew Dilnot.

Care Act reforms

Both commissions reported in 2011 and their recommendations – with some modification – formed the basis of Care Bill, introduced into Parliament in 2013. This passed into law as the Care Act 2014 a year later. On the back of the Law Commission’s work came a national minimum eligibility threshold for adult care; equivalent rights to assessment and support for carers as for service users; a statutory framework for adult safeguarding for the first time; and the entrenchment of prevention as a key aspect of adult care provision. From the Dilnot Commission came the idea of a cap to limit individuals’ liabilities for care to ensure that no one was stripped of substantial assets as a result of their needs. The Law Commission-related proposals were implemented in April 2015; the Dilnot ones were due for implementation a year later.

This reform agenda was piloted by two Liberal Democrat ministers of state for care services – Paul Burstow and Norman Lamb – who were popular with the sector, as were the reforms as a whole.

The start of the cuts

By 2015, however, the social care sector had experienced four years of retrenchment in the shape of the government’s deficit reduction strategy. Its key event was the 2010 spending review announcement by Chancellor George Osborne. The PR for adult social care in this settlement was good: the government had found an extra “£2bn a year” to fund the sector from 2011-15, half of it in transfers from the NHS and the rest in government grant.

But while the NHS transfers were real enough, the additional government grant was an illusion. Local authorities as a whole were to be hit by a massive reduction of over a quarter in their government grant – the additional funds for adult care simply tempered this reduction for councils with social services responsibilities.

Whatever the overall figure for cuts in government grant, their impact fell very unevenly across the country. Poorer areas, more reliant on government funding than locally-raised council tax, were the hardest hit in terms of resource, while they often had to deal with the increased strain put on the social care system by economic dislocation.

Wealthier areas with larger local tax bases were better off though they had to deal with the impact of substantial demand pressures from an ageing population and increased life expectancy among disabled people.

How councils managed

Councils generally got on with the business of making the best of the situation. Authorities shifted a greater proportion of their resource into adult care than before, leaving other services to pick up the tab (including related ones such as supported housing). And many strove ever harder for efficiencies in the way that they operated, investing in preventive interventions such as reablement and telecare to reduce demand, outsourcing or closing expensive in-house care services, squeezing fees for providers and raising charges for service users.

Such efforts made it difficult to interpret official statistics. For example, was the 509,000 reduction in the number of people receiving a social care service from their council from 2008-9 to 2013-14, an indication of a colossal increase in unmet need, or a manifestation of the success of initiatives to reduce demand?

Whatever the truth, having to do more with less and/or substantially cut services left councils in a vulnerable position when it came to implementing the Care Act.

Cheshire West impact

This was made more challenging still by the external shock that was the Supreme Court’s Cheshire West judgement in March 2014: an effective reduction in the threshold for a deprivation of liberty that led to a tenfold increase in Deprivation of Liberty Safeguards caseloads for councils.

Despite it all, councils reported positively on their implementation of the Care Act, perhaps too positively. A succession of progress “stocktakes” by the Local Government Association, Association of Directors of Adult Social Services (ADASS) and Department of Health expressed extremely high levels of self-confidence in councils about their implementation of the April 2015 reforms.

But while councils were confident about the April 2015 reforms, they were much less confident about the April 2016 changes looming on the horizon, namely the far-reaching changes to the system of funding social care. At the heart of these was the extension of the social care system to many more self-funders who wanted to be considered for the cap on their care costs, requiring social care practitioners to carry out many hundreds of thousands of additional assessments.

From coalition to Conservative

As coalition government turned to Conservative government in May 2015, councils lobbied hard for the Dilnot Commission changes to be halted on the grounds that authorities could not afford to implement them. The new minister of state, Alistair Burt, agreed and in July 2015, announced that the reforms would be halted until 2020. It is questionable whether they will ever see the light of day.

Meanwhile, there is increasing evidence that the first phase of Care Act reforms are proving a challenge for the system with reports of shortfalls in access to advocacy and failures to deliver on the new rights for carers, and a high-profile challenge to one council’s fulfilment of its statutory duties under the act. Just 36% of directors are now fully confident that they will be able to meet their statutory duties this year, falling to 8% next year, according to ADASS.

The last major staging post for adult social care in the Cameron era was the 2015 spending review, which set government spending limits for 2016-20. Local government, provider leaders and social care-related charities joined together to lobby for more funds for adult care.

Unexpected funding

Unexpectedly, they got their wish. The government announced that councils would be able to levy an additional 2% “precept” on council tax each year from 2016-20, which it said could raise an additional £2bn a year by the end of that period. Councils would also get more money through the Better Care Fund (BCF) – a pooled budget designed to support the integration of health and social care – amounting to £1.5bn by 2020.

But as with the 2010 spending review, the devil was in the detail. Due to a massive overall cut in government grant, authorities were on a whole due to see a real terms reduction in resource of 7% from 2016-20, even with the additional money through council tax and the BCF. The BCF funding was also back-loaded, meaning it would only come through in any significant sense from 2018-19. And because wealthier areas earn more in council tax, the benefits of the precept will flow more to those parts than deprived localities, though ministers have taken steps to redress this issue through other funding mechanisms.

Living wage impact

If that wasn’t enough, social care was also facing a significant increase in its cost base through the introduction of a national living wage for workers aged 25 and over from April 2016. Latest figures from ADASS show that the money raised from the precept has not been enough to cover the additional costs of the living wage in 2016-17, let alone any additional cost pressures on the sector or the gaps left by reductions in the previous years.

So the David Cameron legacy for adult social care is decidedly mixed. If the Care Act’s reforms become truly embedded over the coming years, despite the financial context, his tenure could be seen as a partial success; if they do not, it is likely to have been viewed as a failure.