Care cuts: ‘If it meets needs and costs less then we have no choice’

When Robyn Noonan thinks about the impact budget cuts have had on the learning disability service she manages, one conversation with a young person comes to mind.

“They came up to me and said ‘my only friends in life are my paid carers’,” she says.

“If someone is not confident, which is often the case, they want a worker to come with them to an activity, maybe for the first few times, to have conversations and help develop relationships.

“When looking at the money, it’s quite difficult to say that investing in helping people to have friends and develop personal relationships is an eligible need, but we know from a wellbeing point of view that stuff is really important.

“If people are going to have a good life in their community then they need more than paid carers. These are the things that impacted when the money goes.”

In social care the money continues to ‘go’ too. Last month, the Association of Directors of Adult Social Services warned that services across the country face a funding gap of almost £1bn this year. Running out of options to save cash from “operational efficiencies”, council bosses feel forced to find savings from frontline services, say ADASS, meaning those receiving support are likely to feel the impact.

The main tool the government has offered councils to raise funding to meet the pressures is the ‘social care precept’ – a 2% council tax levy ring-fenced for adult social care.

Linking funding to council tax means the amount each local authority can raise from the precept varies hugely. Oxfordshire council, where Noonan works, fares better than many thanks to its high council tax base. Yet, even taking this into account, the local authority needs to find adult social care savings of around £35m per year between now and 2020.

John Jackson, Oxfordshire’s director of adult services, says the ageing population means demand has been rising each year too, and this has led to difficult choices about how to spend the limited funding available.

‘Eligible needs only’

Between 2010 and 2015, Oxfordshire’s approach was to try and find efficiency savings by negotiating prices with care providers or redefining contracts when they came up for tender, says Jackson.

“The second thing we did was look at changing the way care is provided, in a way that is better for service users but less expensive for the council.

“There’s next to no care home provision for people with learning disabilities in Oxfordshire but some people are placed out of area, so we’ve looked at bringing them back, for example.”

But as the pressure on budgets increased, frontline services took a hit too. In the last year, for example, Jackson has cut back on some preventative services, an area he’d previously worked hard to protect. This has included cutting the amount spent on homelessness services and on housing related support for people who don’t have eligible care needs.

“We’ve done a lot of things already and we were running out of ideas. We couldn’t rely on cutting the costs to providers because they are under a lot of pressure themselves, so we’ve had to protect the resources available to meet eligible care needs.

“We are committed morally, legally and financially to doing that, but it means we’ve had to look hard at those preventative services that we can’t necessarily link back to reducing demand.”

‘Unprecedented demand’

Learning disability services specifically have been struggling with unprecedented demand. In one year, the number of people requiring support “massively” exceeded the expected level and Jackson has had to seek short-term funding from the council to respond to it.

“We’re in the process of bringing that level of demand in line with the projection we would have had based on demographic growth over several years and we’re delivering on that,” he says.

“But part of that is about changing provision – can supported living be delivered in a less expensive way, for example – and it is also about having some difficult conversations with service users and their families about whether the care package they are currently receiving is more than they would be entitled to in terms of meeting their eligible needs.”

One example of this is education provision for people with learning disabilities, says Noonan.

“We fund people to go to what are really, really expensive residential schools because that’s often what families want, but now if we can meet someone’s educational needs in the county then we’ve got do that, because it costs so much less,” she says.

“However, in doing that there’s a danger skills won’t be developed as well as they might have and the individual’s ability to do things for themselves as an adult becomes more difficult.”

‘Limited choices’

Noonan has seen her team’s budget cut by around 20% in the last two years. While she’s confident the service, which now supports just over 2,000 adults, can still meet its legal duties, she says preventative services like travel training have taken a hit.

“If you can teach someone how to use public transport then that’s a much better outcome for them, but it might not necessarily fall into what we call an eligible need. Those things are tending to fall by the wayside a bit and there’s definitely less choice.”

This “absolutely” impacts on the service user’s independence, she adds.

“If people see their siblings or family going on public transport, they will want to be able to do that – they have the skills and ability to learn, but just need that little bit of extra time…In the majority of cases we are still finding a way to do it, but there will be some occasions where we’re not doing it and we would have done it before.”

The choice of daily activities available to people is also becoming more constrained.

“Sometimes, if an activity doesn’t cost as much but meets the person’s needs we have to say unfortunately that other option is no longer available,” Noonan says.

“We’ll try and be flexible because we have to look at that person individually, but if there’s a big difference [in cost] then we kind of haven’t got a choice.”

‘Wellbeing vs. eligible’

Noonan says there have been some examples where tightening budgets have forced staff to think more creatively about the way support is delivered and find local projects that can help people take part in activities they enjoy doing.

“If someone really likes gardening and enjoys being outside, for example, previously what we would have done is send them to a day centre, where they could do a bit of that.

“Now we try and form that relationship with the garden centre instead and enable the person to do some voluntary or paid work there.”

But asked if the cuts are impacting the service’s ability to meet the personalisation agenda, Noonan is torn: “It depends whether you mean the principle or the outcome really.

“The principle we can still do that because it’s about involving people and ensuring they can make the choices within their budget, which we’re doing. But I think personalisation from the point of view of being able to give people the skills they need is more limited.”

What is the experience of people receiving services? Pam Bebbington is chair of My Life My Choice, an Oxford-based self-advocacy group for people with learning disabilities.

She says the organisation is worried about the impact the latest round of cuts to services will have on its members but is glad that the council continues to fund self-advocacy work to ensure people can make their views heard.

“We know that local authorities are under enormous pressure to cut budgets, so this demonstrates the commitment of Oxfordshire’s commissioners to people with learning disabilities having a voice, and being able to speak out about the government’s austerity programme”.

‘Pace of work’

As Noonan prepares for the next round of budget setting, a major concern is having enough social workers. The service has recruitment and retention problems, she says, and is heavily reliant on agency workers, which is driving up costs.

“When we talk about the drop in budget, it’s kind of trumped by the fact that if we haven’t got enough staff to do the work, then the budget almost becomes irrelevant,” she says.

“There’s quite a lot of young people coming through and we want to encourage that, but I think what we’re really struggling with is recruiting experienced social workers.”

This is difficult for families because of the lack of continuity, but it’s also had a significant impact on the pace at which social workers in the service are expected to work, she says.

“Social workers come in to do the job because they want to enable people to reach their potential – but they are constantly trying to get on top of waiting lists.

“That’s had a huge impact on morale.”

This pressure has been compounded by the Supreme Court’s landmark Cheshire West ruling, which effectively lowered the threshold for what constitutes deprivation of liberty in care. In doing so, it significantly increased the number of people requiring assessment.

Noonan estimates there are 500 people living in supported living services that need to be assessed to see whether they meet the criteria for a community deprivation of liberty.

“It’s a constant balance between trying to see all the people that we need to see and the fact that most of those people are in services and being supported, as opposed to those who might have a more urgent need,” she says.

The council is in the process of training all social workers to become best interest assessors, but Noonan says that’s another balancing act in itself.

“There’s no extra money for this – if we target money at it, it’s coming from somewhere else.”