Social Care: The Challenge For Councils – Dame Denise Platt DBE
What social care will look like in the future, and how it will be funded – is one of the most pressing challenges in public policy.
The number of people who need care services is increasing, as the population gets older and the number of adults with disabilities rises. The challenge for policy-makers – nationally and locally – is to ensure that access to care services is fair, equitable and transparent. People need to know what is universal, and what they may be expected to contribute.
I’m pleased to say that the spotlight is on social care right now in an unprecedented way. From being the ‘poor relation’ of public services, social care has at last moved centre-stage as policy-makers recognise the essential role it plays in people’s lives – and the need for a new settlement on how it is funded together with new models to deliver tailored services.
Today I want to set out the main social care challenges for councils, as I see them, based on what the Commission for Social Care Inspection has found in our inspections, regulatory activity and performance assessment of councils over the last year:
· Making access to social care services fairer and more transparent;
· Providing information and advice to everyone who needs care and support;
· Tailoring care and support to people’s individual needs, and delivering the vision of ‘personalisation’ set out in the Government’s ambitious transformation agenda;
· Making personalised care a reality for people with multiple and complex needs; and
· Commissioning for whole communities – making the area served by a particular council a better place to live, for everyone.
Making access to care services fairer
I am sure you all know that in CSCI we are preparing to wind up our work very soon, as responsibility for inspecting and regulating social care passes to the new Care Quality Commission at the beginning of April. Looking back, I consider that the biggest long-term contribution we have made has been through our annual, pull-no-punches ‘State of social care’ reports to Parliament. This series of reports has offered a comprehensive overview of social care in England – a complete picture of care across the public, private and voluntary sectors, with our starting-point being the perspective and experience of people who use services.
Two years ago we focused on the challenges which faced carers; last year we focused on the situation for people who are not eligible for publicly funded social care, and who have to find and fund their own care. We highlighted the increasingly sharp divide between people who qualify for care that is funded and arranged by their local council, and those who fall outside that system. While the overall quality of care is improving for people who are eligible to receive services, the number of people who do not meet increasingly restrictive criteria is growing – and these people are, effectively, ‘invisible’. A year on, we find that this divide still exists – and in many places is sharper than ever. People who are excluded manage as best they can, but this is often at great cost in financial, emotional, personal and physical terms. They either have to find and fund their own care, rely on family or friends for support – or do without. The system is fast becoming a system that can only provide complex responses to people with complex needs – too many councils equate so-called ‘low level’ services with ‘low eligibility’ and such services cease to exist.
So CSCI was pleased to be asked last January by Ivan Lewis, who was Care Services Minister at the time, to undertake a review of the current eligibility criteria – ‘Fair access to care services’ – that councils use to make decisions about how and where to allocate resources. We presented our findings to ministers in the autumn, together with recommendations on the way forward (set out in our report ‘Cutting the cake fairly’).
We found that people looking for support often find that their needs are not fully considered, and that advice about the options open to them is hard to come by. We found that while it’s generally acknowledged that some method is needed to help councils decide who should receive publicly funded care, there is much criticism of the way that eligibility criteria are applied in practice.
People’s concerns centred on the perceived lack of transparency and fairness in the way councils apply the criteria – and the apparent incompatibility between the current system and the Government’s ‘personalisation’ agenda. While most people accept that the state can’t fund or provide everything, they want a fairer and clearer system.
CSCI has made a number of recommendations to ministers, designed to achieve two things. First, to challenge traditional thinking on social care services. And second, to improve the operation of the system for allocating public funds to individual people.
Providing information and advice to everyone who needs care
It is our firm view that everyone looking for support should be entitled to information, advice and a proper opportunity to have their needs assessed. They should have access to good information about their options, and independent advice to help them make decisions – someone to talk to about the right care for them, not just a list of care homes or care agencies.
We would also like to see a clearer and simpler framework for deciding who is a priority for publicly funded support. ‘Cutting the cake fairly’ calls for a national resource allocation framework to underpin individual budgets, so that rather than each council devising its own system, there would be a common approach across the country, and a common approach to the situation of carers. How councils allocate financial resources within the framework would be a matter for them. A common framework would increase transparency – and should also make it easier for people to take their assessment from one local council to another if they move home – the portability issue.
Social care in the future should be delivered within a single system – regardless of who is paying. We need to end the ‘no help here’ culture that prevails in too many councils – so that no-one is excluded from assistance in gaining access to the care and support they need to manage their lives.
Tailoring care and support to people’s individual needs
Our most recent ‘State of social care’ report, published two weeks ago, looked at the extent to which people, especially those people with multiple and complex needs, are benefiting from the personalised care agenda set out in ‘Putting people first’ – the Department of Health’s protocol, published just over a year ago, that outlines the Government’s vision for a wholesale transformation of social care services.
Since CSCI began work in 2004, we have seen significant improvements in council performance in supporting people through direct payments as the numbers of people using direct payments have significantly increased. So has the number of people receiving services in their own homes to allow them to remain independent. There has also been a 25 per cent increase in the number of carers receiving support. Across the country we have seen councils investing in a range of preventive services and working with partner agencies, including the NHS.
But –over the past year we have found that there are real challenges in making personalised care a reality. Assessment and care planning are not yet sufficiently person-centred and holistic. Many carers still feel unsupported, and excluded by some resource allocation formulae. Advocacy services are limited. In some places assessments of people’s needs are not universally available. ‘Personalisation’ requires more self-assessment, and emphasises individual choice and control – but, as our eligibility report showed, too often council assessments appear to be based on financial capacity rather than need, or an assessment of a person’s need is preceded by an assessment of their financial circumstances. No council yet has a systematic approach in place for people who direct their own support.
My concern is that, while many councils are improving their performance in the context of what is currently required of them, it isn’t clear how they will go about planning and delivering the transformation agenda of ‘Putting people first’.
For example, in our special study of people with complex needs – we have found that there are reservations in many councils about who can make use of personal budgets, and whether the system is affordable. But it is important to remember that direct payments and individual budgets are not an end in themselves, but rather a means by which care services can be tailored to people’s individual needs. And they are much more than an alternative mechanism for shifting money around the social care system. They fundamentally alter the traditional relationship between people and councils, handing back real control to individuals – and to carers, who can use the money to buy themselves time to reclaim their lives.
But for those people who do not want to handle the money themselves – the principles of control and choice, of tailoring care to the person’s needs, still remain – they should have the power to direct whoever holds the money (even if that is the council itself) and to tailor the support it funds.
All councils expressed concern to us about getting the right balance between choice and control, and increased risk. There is a real need for strong leadership – specifically political leadership – in support of personalisation. A service manager at one council told us:
“The politicians were very resistant to Direct Payments. They have a real problem with the inequity of it and the impact on the workforce – that it could be the end of the in-house provider. They felt that if you got money through a Direct Payment then you could choose something that people without a Direct Payment couldn’t choose, therefore nobody should get the choice.”
Some people have called our report ‘gloomy’. We disagree: it is realistic and reflects the current experience of the majority of people. Although it is early days, our report should be seen as an ‘early warning’ – the big idea is right; the government has made resources available; it is right to be ambitious; but progress is distinctly patchy. Councils appear, unsurprisingly, to have focused their attention up to this point on people with the most straightforward requirements – but many people still experience a ‘one-size-fits-all’ model of care that is not geared towards their individual needs. The move to make personalisation a reality for everyone will take persistence and rigour on the part of councils.
Making personalised care a reality for people with complex needs
As I have said, a particular challenge for councils is making personalised support a reality for people with the most complex needs. There is little consensus on what is meant by ‘multiple and complex needs’ – people can be segregated according to the reason for their impairments, as well as other factors such as age. But we know that personalisation models are insufficiently developed for these people – individual budget pilots have so far primarily concentrated on people whose requirements are fairly straightforward. All councils in the special study we completed as part of the most recent ‘State of social care’ report – even the most enthusiastic and committed – were struggling with the requirements of moving from pilots to mainstream services.
People with complex needs require coordinated services and excellent partnership working.
And good personalised care is dependent on the availability of suitably skilled and trained staff – but vacancy and turnover rates are high, and they are growing. To illustrate: the number of Care and Home Care Assistant vacancies notified to Job Centres almost doubled between 2003 and 2008. We are advised (by Skills for Care) that at any one time between 98,000 and 120,000 vacancies exist in the sector – we register 24,000 services – that averages out at 3 vacancies per service – where will the trained workforce come from?
Commissioning for whole communities
The biggest challenge of all for local councils is to become effective commissioners for the whole community they serve.
The role of councils is changing. The Community Care reforms of 1993 reinforced the position of councils as mediators between individuals and service providers: the market place. But the transformation programme of today goes right to the heart of the relationship between the citizen and the state – these reforms are about empowering individual people to have a direct, responsive relationship with the people or agencies that provide their care and support. The role of the professional is to support, not control.
So the role of local councils is as important as it has ever been, but they need to recognise that they are responsible for everyone in the communities they serve – not just those people whose care and support they expect to fund, but also for those who arrange and pay for their own care.
Commissioning is at the heart of effective social care. At CSCI we think councils should ask these sort of questions:
· What is it like to be an older person, a disabled person, a person with mental health needs, living here?
· Can people find the services they need?
· Can people living here grow old in the way they want?
· Can people with learning or physical disabilities living here find employment, have a home, a family?
· Can people with complex needs get the help and support they need moving into adulthood?
· If people living here have responsibilities as carers, can they get the help and support they need?
And if the answer is ‘no’, or the council can’t answer the questions (and no one agency can answer these questions in isolation – meeting the challenge requires acting in partnership with others), these are the commissioning challenges they need to address. This is the council’s ‘place-shaping’ responsibility – ensuring the community is a better place to live. And these are issues which the Comprehensive Area Assessment will probe.
The next few years will be a crucial time for adult social care in England, with important decisions due to be made on the future shape of the care and support system, and about the way the system is funded – as well as a major transformation agenda to be delivered by councils.
This is unfinished business that CSCI would pursue if we were continuing our work. As it is, it will be a matter for the Care Quality Commission to assess the extent to which people are benefiting from policy changes designed to make care more personalised, and to determine whether choice and control have truly become a reality for people who rely on social care services to help them live their lives.