The Coalition Government’s Programme for Social Care – which contains key words such as control, dignity, respect and prevention – is setting a new scene. But with far reaching cuts in public expenditure expected, and no talk of protected funding, what are the implications for service users, carers, local authorities and the wider public?
The Department of Health defines ‘social care’ as “the wide range of services designed to support people to maintain their independence, enable them to play a fuller part in society, protect them in vulnerable situations and manage complex relationships”. According to the NHS Information Centre, in 2008 approximately 2.5 million older people (aged over 65) in England – 30 per cent of the older population – had some difficulty with activities such as dressing, eating, washing and going to the toilet. Of these, it is estimated that 1.2 million older people used social care that was provided, purchased or supported by a local council (including equipment and adaptations to people’s homes).
The previous (Labour) government’s Green Paper ‘shaping the future of care together’, Big Care Debate and White Paper ‘building the national care service’, looked at how to address a postcode lottery around care. Their proposals included a comprehensive ‘National Care Service’ for all adults in England, with care provided free when they need it. Although the promise of an Independent Commission on Social Care Funding contained in these earlier policy documents is being taken forward by the new (coalition) Government, a consideration of all possible funding options may mean providing a universal system of social care remains aspirational.
The Coalition’s ‘Programme for Government’ is littered with references to adult social care. The NHS section sets out a commitment to ‘help elderly people to live at home for longer through solutions such as home adaptations and community support programmes’ (page 25). The pensions and older people chapter describes ‘protect[ing] key benefits for older people such as the winter fuel allowance, free TV licences, free bus travel, and free eye tests and prescriptions’ (page 26). In public health there are references to ‘give local communities greater control over public health budgets with payment by the outcomes they achieve in improving the health of local residents’ (page 28). In the section on social action, there are dual pledges to ‘support the creation and expansion of mutual’s, co-operatives, charities and social enterprises’ and to ‘give public sector workers a new right to form employee owned co-operatives and bid to take over the services they deliver’ (page 29). Finally, in the dedicated chapter on social care and disability is a guarantee to ‘extend the greater roll-out of personal budgets to give people and their carers more control and purchasing power’ (page 30). Although social care is set out in five separate sections, if they are taken as a collective, the Programme appears to move towards providing more control to individuals and their carers whilst easing the cost burden that they and their families face.
But what are the opportunities and challenges of this in practice? How can public services support some of the most vulnerable members of our society (in this case, older people) to carry on in their daily lives? I would like to offer three points.
Firstly, funding and the criteria used to determine ‘who’ and ‘what’ care is provided for older people. Social care in England is funded through central government funds allocated to local councils, council tax revenues, individuals’ contributions to their local authority care package, and/or to services arranged independently. The voluntary and community sector also provide and subsidise a range of care services. Councils with social services responsibilities (unitary and county councils) commission social care services for their local communities. Councils use the national Fair Access to Care Services (FACS) Framework to categorise an individual’s level of need – there are four categories: low, moderate, substantial or critical. Each council then has its own budget for adult social care and decides which of these four needs bands it will fund (for example, some councils fund moderate needs, others cover only the critical band). Anyone below their council’s needs eligibility threshold must pay for their own care. In England, an adult who is eligible to receive social care undergoes means-testing to determine how much they will be expected to contribute to the cost of their care (under current guidelines an individual with assets of more than £22,250 receives no public financial support). For me, this raises questions around whether the current funding formulae and eligibility criteria is about rationing resources or delivering better outcomes. For current funding and assessment approaches appear to operate on a risk based system and the affordability of service provision.
Compared with FACS, the emergence of the personalisation agenda means that some service users are now given a personal budget to buy their own care and support. Figures published by the Association of Directors of Adult Social Services and the Local Government Association reveals that personal budget funding levels have now reached almost £900m of council expenditure, with 74% of this delivered as a direct payment. The survey found that 96 councils committed more than 10% of their community services budgets through a personal budget and 40 committed 20% or more of such funds. However, the financial viability and logistical implications of delivering personalised services – of offering rural residents real choices and control - is often limited.
With the cost of care in England from 2007 to 2026, expected to nearly double in real terms, from £12.7 billion to £24.1 billion (at 2005 prices!) and Age UK predicting a £1.75 billion gap opening up between annual spending on older people's care and that required to keep pace with demand if projected cuts from 2011 to 2013 are implemented by the government, reconciling needs with funding in adult social care presents real challenges – can we afford to continue to implement the personal budgets set out in the Coalition’s Programme for Government?
Thirdly, this briefing raises issues around what gets counted and counts For relying upon cost comparisons across ‘four needs brackets’, following historical spending patterns or somehow trying to take the aggregate effect of hundreds of thousands of personal budget decisions made by older people cannot be the only way to plan the future provision of care. To overcome these issues, a new adult social care outcomes tool called ‘Ascot’ has been developed. Funded by the Treasury (at a cost of £2 million) and created by the Personal Social Services Research Unit, Ascot gauges the effect of a social care service on an individual's quality of life. This is measured by eight factors ranging from personal safety to dignity. The factors can then be weighted according to perceived importance. The tool has been trialled in 170 care homes, producing an average quality of life finding of 0.57 on a scale from 0 to 1, meaning that care home life enhances well-being by 57%. Interestingly, while homes rated good or excellent by the Care Quality Commission did achieve better results, the attributed variation was marginal. Ascot and similar approaches may move us closer towards measuring the things that matter most to service users and carers by focussing on outcomes and how the lives of older people change as a result of government policy.
By 2026 there will be 1.7 million more adults who need care and support. I am currently one of more than six million unpaid carers in the UK. Three out of every five people in the UK will become carers at some time in their lives. For those of us already immersed in the maze of adult social care a road map setting out what and where future economic investment will come from (no longer should funding for adult social care be seen as ‘dead money’) and how ‘we’ (users and carers) will be able to shape the design and delivery of services is vital.