How do we create a personalised and financially stable social care system?

By Colin Slasberg

The British Association of Social Workers’ (BASW) response to the green paper principles contains, among other ideas, three arguments that hold the promise of a personalised and financially sustainable social care system.

The first principle expresses the view that assessments of need should not be compromised by resources. Meanwhile, the second says decisions about allocation of resources should be transparent and follow the assessment.

This would mean the separation of two key decisions that have, historically, been fused into one; how much resource is sufficient to meet a person’s needs, and how much is affordable?

The evidence is clear as to what happens when these two decisions are fused. Affordability drives decisions, but this is given an acceptable face when it appears to be motivated by sufficiency. This is achieved by dressing decisions up in the language of eligibility criteria.

It’s a system that enabled Sir Chris Wormald, permanent secretary for health, to tell the Public Accounts Committee there was already sufficient money to meet all statutory requirements under the Care Act. It’s a statement that is always true, no matter how large or small the budget.

BASW’s proposal to separate the sufficiency and affordability of decisions would signal an end to a dysfunctional and dishonest system. But crucially, it opens the way for a third key principle contained within its statement.

Changing focus

Independent living should be adopted as the vision for the future system. Yet, a model which is always looking to make ‘need’ fit resource is not capable of developing a vision of how life should be for people.

The Care Act requires councils to promote wellbeing, but it does not say to what extent they should do this. That is left as a matter of policy and it is an issue the government has so far ducked.

BASW’s statement would have to include ‘need’ to be understood in the context of what it will take for the person to achieve independent living.

As defined by the United Nations, independent living applies to people of all ages, with a central concept of having choices equal to others.

That can apply to an older person wanting to go to bed at a time of their own choosing just as much as a younger person wanting to engage in activities along with those of their age.

The concept of full and equal participation in society can mean an older person wanting to remain an active and valued family member just as much as a working-age person wanting to contribute their talents to wider society.

The separation of sufficiency and affordability will, inevitably, mean any gap between needs and resources will be exposed.

At first glance, people might wonder why this will improve the fortunes of service users and carers. But a moment’s reflection shows the benefits will be manifold.

Assessments

Assessments will cease to be conducted on the basis of obscure, profession centric eligibility rules. Instead, they will revolve around the person’s unique, lived experience of needs for independent living.

The assessment will be conducted on the service user’s terms and authentic control will become a real possibility for all, not just the small minority with the skills time and energy to escape the mainstream system and manage their own support.

Moreover, if a person’s full needs cannot be met, support will be targeted on what really matters to the person.

The concept of ‘greatest need’ is the basis of the current system of resource allocation. This requires people to minimise their strengths and maximise their deficits to gain support, thus promoting dependency.

If ‘need’ is no longer shaped by resource, but by a vision of how life should be, ‘greatest impact’ could replace ‘greatest need’ and outcomes could replace deficits as the basis for resource allocation decisions. The idea of prevention will be able to come in from the margins and take centre stage.

Meanwhile, needs requiring public funding that cannot be afforded immediately will remain a responsibility of the council, who will keep such needs under review.

Know the gap

While the current system denies any gap between needs and resources by always adjusting ‘need’ to resources, councils for the first time will know the gap. They should be required to aggregate the information.

The democratic system, both national and local, will know how much it will cost to deliver a decent and civilised service fit for a modern society.

Current estimates of the funding gap are based only on keeping the current dysfunctional and wasteful system afloat. While necessary in the short term, it is not a basis for a sustainable future.

The evidence now makes it inarguable that the level of need met is determined by the level of resource. This is a political responsibility.

The pretence that the level of need met is determined by eligibility criteria makes challenge a judicial matter, which is costly, intimidating and invariably futile.

Courts have tended to test only a council’s application of process in its decision making, thus setting the bar very low. People who wish to make representations about their level of support will know the right route is the political, not judicial, system.

BASW plans more work to flesh out the substance to deliver these principles. But, only time will tell whether the statement becomes just another high-minded document that remains on a shelf or, becomes the template that initiated real and sustainable change.

Colin Slasberg is a social care consultant and a former social worker and council manager