Over the past few weeks, oh, who am I kidding, over the past few years, I’ve been pondering the way that adult social care is structured in this country from the position of having worked in this area over a number of years. I have seen many changes but anyone who has been involved in social care for more than a year could probably say the same. If there’s one thing that is sure about statutory social work/social care, it’s that the next reconfiguration or improvement is just around the corner.
In my renewed spirit of positivity though, I thought it would be worth reflecting personally on some of the changes I have worked through and look at some of the directions we are going with a thought to what I would do if I were in a policy-making position rather than the position of a front-line practitioner.
So I entered social work in the shadow of the changes pushed through by the NHS and Community Care Act (1990). We were moving from ‘social work’ into care management and this was going to be an improvement for those who used the services as local authorities were going to be contracting out/selling off their own centrally run and ‘inflexible’ services to new, private and voluntary sector providers who would be far more flexible about meeting the needs of individuals.
When I think back to those heady days, the ideas weren’t so different to the ways that the personalisation agenda was presented. Direct Payments were just about to start but the idea was that care would be planned by a care manager to put the service user at the heart of the process and more interesting, more exciting and more specialist services would be commissioned for the same ‘pot of money’.
We were also sold talk of community involvement rather than segregration – gyms instead of day centres - but the day centres remained and the processes weren’t flexible enough to allow the choices that should have been there.
So Direct Payments were introduced, first as an option and then as a right. They led from the ILF (Independent Living Fund) model of giving mostly younger adults (because you had to be under 65 to qualify for ILF) with physical disabilities a pot of money and a choice of employing a PA directly.
Quite rightly, this model was seen as positive and there were attempts to spread this more widely to all user groups. The take up was much higher in some user groups than others, strangely (I’m being ironic – bear with me) related to access to greater ‘pots’ of money or more informal support.
There has also been a massive push and development of carer services. It might not seem it to those who devote themselves to caring for family members or friends but there are now statutory rights to assessments and increasingly service provisions directly for carers.
And so we moved through to the Putting People First agenda of pushing the right to a personal budget for care services to everyone who uses and is eligible to support.
It is the right direction absolutely. Increasingly choice and control for social care packages is and must remain at the heart of social care provision for adults in the UK but there are genuine practical problems.
Firstly that too often councils have just shifted people who have been more difficult to engage in the process of choosing in the way the LAs want them to choose onto ‘managed’ budgets where the LA implements the care for the user and essentially makes the choices for them leaving very little different.
Secondly, the provision of 24 hour residential and nursing care has been lost in the push towards choice. It feels a lot like an poorly regulated afterthought when actually provision of residential and nursing care can be the most important decision in someone’s life and affects life quality absolutely.
Thirdly and by no means lastly, funding issues.
There is not enough money to pay for good quality care services for all who need it so the decisions are made about who will pay and how they will pay. The Dilnot report offers some potential solutions, personally, I don’t think it goes far enough.
The fact is that people don’t want to pay for care. They don’t want to pay for care related to health needs. People believe it is a right to receive care free. But that isn’t the case. Care costs and it is means-tested.
The postcode lottery comes into its own here with charging policies varying massively. On the ‘ground level’ I know people I assess and review are increasingly refusing care I feel they desperately need purely on the basis of cost. This shifts costs from self and social care onto health in the future, but at least health costs are free to the individual.
Personal budgets are not going anywhere and must be embraced and embraced positively as they are supposed to be. We must look past some of the cynical ‘target fixing’ of the local authorities who want to prove they are doing better on ‘choice’ and really adopt a strong advocacy role in using them the way they were intended to do and keep pushing and pushing until they deliver the promised change in terms of outcomes for all users of adult social care rather than relying on a few old examples. They must work but they also must work better.
Charging policies must change and this is in the offing. While I don’t agree 100% with the Dilnot recommendations, it is better than what we have. We need transparent and equitable methods to fund social care that don’t regard the sector as an afterthought.
Promotion of advocacy to all user groups who don’t have informal networks and particularly to those who may have issues with capacity is essential to back up and check on progress of professionals and local authorities who have different budgetary agendas. We have to offer support to challenge on an equitable basis.
Our systems have to be more flexible, as professionals within local authorities we have to have access to different styles of commissioning that include micro-providers. We have to have access to different communication formats and promote more interactive feedback using more technology to those who find it more useful while backing up with face to face contact, discussion and feedback for those who don’t.
Our world is becoming more fragmented as we have more access to information sources and accept that people cannot be defined merely by needs identified in traditional style assessments. We have self assessments now but they are more similar to DLA forms based on ability to wash and dress rather than building holistic pictures of who and what someone is. That is what is needed. Yes, it will be labour intensive but we need to find more value in quality and more value in the individual.
Where will be money come from to do this and to make these changes? Well, I think that better quality and treating people as human beings has so many longer term benefits regarding outcomes that it will be a saving and not just in value but in quality of life.
Is the system broken? In parts. But the people who work in the system aren’t and nor are the people who use and need it. We need to build it back up together. Co-production has to be the answer.
These are exciting times for adult social care – lets build a positive from too many negatives and make things better.