By Pete Feldon
The received wisdom is that adults and carers are experiencing significant unmet care and support needs, and more resources are needed to address the problem.
In England, the Association of Directors of Adult Social Services (ADASS) says so, and figures produced by Age UK are often quoted in the national press – “A million older people ‘badly let down’ by lack of social care funding”, one article read.
In light of this, it could be expected that the numbers of people complaining to the Local Government and Social Care Ombudsman (LGSCO) about local authorities refusing to meet their care and support needs would be relatively high. Yet, very few people actually complain about decisions not to meet their needs where these do not meet the eligibility criteria.
However, there are a significant number of people who complain about their needs being under-met; this occurs when a person – judged to meet the eligibility criteria – believes their personal budget is insufficient to meet their needs.
References to unmet need
From my own analysis of investigations listed on the LGSCO website, I found that there were 315 complaints made to the watchdog in the last financial year where the investigation was concluded in the ombudsman’s category of assessment and care planning.
The figures for 2016-17 and 2017-18 were higher, at 402 and 384 complaints respectively. Of these, there were references to unmet need in seven cases in each of the first two years; there were nine last year.
The most frequent reason for needs being unmet was as a result of delays, most commonly in assessment/reassessment or putting in place elements of the care and support plan.
There is only one example out of these 23 cases of an individual successfully overturning a decision about needs being deemed ineligible. However, there were a handful of cases where the ombudsman recommended a review, as the original assessment was seriously flawed. But, it is not known whether this resulted in unmet needs subsequently being met.
Having said this people don’t always set out their complaints as being about unmet need and neither does the ombudsman interpret them in this way. So, I next looked at complaints that either made reference to personal budgets or needs not being eligible.
There were nearly 300 upheld complaints in this three-year period that include reference to personal budgets and, of these, one of the main complaints was about reductions in the personal budget, resulting in some of the individual’s eligible needs not being met or being under-met.
Of the 147 complaints that made reference to needs being not eligible, most were from people who were already receiving services, but it is difficult to ascertain any common themes.
No place in statute
It is understandable that addressing unmet need per se is not at the forefront of complaints because there is no statutory definition of the term. In fact, there is no reference at all to individual unmet need in the Care Act 2014 and the accompanying care and support statutory guidance.
The legislation recognises that individuals will have care and support needs that are not eligible, which local authorities will mostly not meet, and these are described as ‘non-eligible needs’.
There is a duty to explain the decision not to meet needs and provide information and advice to individuals to assist them in preventing, reducing and delaying needs that have been determined as non-eligible, and this must be done in writing.
But there is no obligation to determine or record whether non-eligible needs are met or unmet.
The ombudsman occasionally makes reference to the fault being partly because of a failure in the duty to provide a written explanation of the decision about needs that are not eligible, but there are only a handful of cases where the decision about the determination of non-eligible needs was deemed as unsound.
Another possible explanation as to why there are so few complaints to the ombudsman about needs not being met, could be that issues are being resolved through local complaints procedures. But there is no publicly available data available on this and, as yet, there has been no research.
But, are there 1.4 million older people in England who could potentially succeed with a complaint about unmet need?
Definitions of unmet need
The Age UK figure is derived from the ‘English Longitudinal Study of Ageing’ (ELSA) that looks at activities of daily living. The definition of need used by Age UK includes individuals who say they have difficulty with at least one activity of daily living and are receiving help from someone – even if it’s just a friend or neighbour.
The minimum definition of unmet need is where the help people receive usually meets their needs but not always.
The Age UK definition of unmet need has been widely adopted as follows:
- The government’s autumn budget 2018 – Representation by The ADASS: “This has left approximately 1.4m people with unmet care needs”;
- The Housing, Communities and Local Government and Health and Social Care Committees’ joint report into the long-term funding of adult social care : “1.2 million older people may now have unmet care needs”.
The Local Government Association (LGA) also quotes this figure in ‘The lives we want to lead’, its own version of the social care green paper and consultation, but it places its focus on other data from the Age UK research.
This shows “164,217 people in England who need help with three or more essential daily activities, such as washing, dressing and going to the toilet, and who receive no help at all from either paid services or family and friends”.
But both of these figures are only about difficulties in daily living for older people and do not take into account unmet care and support needs that relate to other factors.
A joint report by Ipsos and MORI, ‘Unmet Need For Care’, states that “older people raised unmet need for social contact and mobility as being as important, if not more important as meeting basic needs of daily living”.
Nevertheless, there would appear to be significant numbers of people with unmet need.
The more conservative figure of 164,217 means that, on average, there are approximately 1000 older people in each local authority in England with significant difficulties in daily living who receive no help from anyone.
Greater research required
Thus far, very little research has been undertaken into how the Care Act is applied in relation to assessment and care planning. Hopefully this will change as a result of the Adult Social Work Priority Setting Partnership, commissioned by Lyn Romeo, the chief social worker for adults, which recommended 10 priorities for research.
This included questions, such as:
- “How are eligibility criteria applied to people with different types of needs and are the thresholds appropriate?
- What impact does this have on the care and support offered and / or early prevention?”
Some good work has been done by Community Care on research into decision-making in relation to personal budgets using Freedom of Information requests. But getting information by this method relies on the data being available.
Some local authorities keep good records about internal complaints, but they are not currently required to record how many people have been determined as having non-eligible needs (as defined by the Care Act).
It is possible that policy developments may result in some useful information about unmet need being generated. The proposed green paper might have as one of its objectives the improvement of transparency in decision-making.
The LGA has stated in ‘The lives we want to lead’ that there should be a focus “on prevention and picking up unmet need early to prevent escalation”.
The British Association of Social Workers (BASW) has also called for a review of the application of the Care Act, “which should include an evaluation of how potential eligible needs are being reduced, how the criteria operates as a threshold, and how non-eligible needs are being addressed.”
But at present the major source of information about unmet need is through complaints to the ombudsman, meaning case studies derived from these complaints will continue to be one of the major sources of learning in the training events that I facilitate.
Pete Feldon is author of The Social Worker’s Guide to the Care Act 2014 and a social work trainer – click here to view his LinkedIn profile