Fixing Social Care
Boris Johnson has pledged to fix the social care crisis ‘once and for all’. It fits the image of the PM able to forge ahead where predecessors have failed. But does he know what he is taking on?
There are two fundamental problems with social care. Johnson appears aware of only one of them; that people have to ‘sell their houses to pay for care’. This is about the balance of public and private funding, delivered through a means test.
The other problem is the fundamental nature and quality of the service itself. Social care’s desultory and dispiriting impact on the people it serves has been known since the mid 1980’s. There has been a series of supposedly ‘transformative’ strategies. All have failed.
Relaxing the means test will do nothing about the quality of the service. It may well make it worse. It will be costly, up to £7 billion, a 50 per cent increase in spend, mostly made up of people currently excluded by the means test being attracted in. But the system has a pernicious mechanism at its heart - the needs test - which would allow government to relax the means test without fully funding the resulting impact.
The needs test allows what is deemed ‘need’ to be adjusted so demand never exceeds the available resource. A politically popular move would end up being paid for by those on the receiving through further reduction of support.
If social care is really to be fixed, both the means test and the needs test must be tackled.
How the needs test works
When we have a health issue, ‘clinical need’ is established based on the clinician’s knowledge. This follows the principle, set in stone at the inception of NHS, of need preceding resources. When resources fall behind need, waiting times go up creating political pressure.
The reverse is the case in social care. Eligibility of ‘need’ is calibrated to whatever the local council’s level of resource. But ‘eligibility’ is as long as a piece of string. While there are, ostensibly, national eligibility criteria, they are so loose as to have no meaning. Councils must treat as eligible any need that has a ‘significant impact on wellbeing’. The meaninglessness of this phrase merely opens the door for councils to control their spending by adjusting what they consider ‘eligible’ to suit their budget.
Consequently we have an extreme post code lottery. The 10 per cent top spending councils spend an average of £21,000 per service user and the lowest 10 per cent just £11,000. Yet all councils claim to be working to the same national criteria. It is a serious deception
But it’s the gift that keeps on giving to the Treasury and local finance chiefs. Spending is controlled and they can claim no need is ever unmet. The Public Accounts Committee was recently taken aback when Sir Chris Wormald, the Permanent Secretary to the Department of Health, told them councils had the money to meet all their obligations.
Ironically, the needs test results in inestimable waste. People have to establish their situation is worse than others to determine eligibility. Its a system geared to crises. If one doesn’t exist, it has to be created. The result is needless dependency.
This is also deeply damaging. When people are struggling with impairments of mind or body, it’s the easiest thing in the world to depress and discourage them. The sector is currently promoting ‘strengths based’ approaches to counter the problem. Grafted on to an unreformed system they are doomed to join the ever growing litany of failed attempts at transformation.
Ending the needs test
Spending must, within a democratic society, be contained within whatever budgets have been made available. But it doesn’t have to be through the needs test. ‘Need’ should be identified against whatever it will take for the person to have the quality of life right for them. How much can be afforded should be a subsequent decision. Affordability of need should replace eligibility of need to control spending.
The change is both legally and financially possible. Government can continue to fund social care to whatever level it chooses. What will be different is that any gap between needs and resources will become known. Political leaders will have to accept their responsibility.
The progressive way forward
The needs test is the rock upon which all attempts to make social care fit for a modern society have foundered. Any progressive solution will require leaders who believe pursuit of best possible wellbeing should be addressed in the same way as best possible health of mind and body. Any gap between needs and resources should, as for the NHS, be known and acted upon. So far it does not look as though our new Prime Minister has grasped this point.
Professor Peter Beresford is author of All our Welfare: Towards Participatory Social Policy, Policy Press. He is emeritus professor of social policy at Brunel University London, professor of citizen participation at Essex University and co-chair of Shaping Our Lives
Colin Slasberg qualified as a social worker in the 1970's and after a career in practice, operational and strategic management, in recent years has worked independently to focus on what it will take to create a system that is authentically person-centred.