A profoundly institutionalising system

Directors of Adult Social Services are acutely aware that social care can face one of two ways. At its worst it diminishes the people it serves, making them needlessly dependent. At its best social care elevates people. It makes lives the best they can be by making the best use of resources.

Directors believe social care has long been rooted in the former. For the past decade, they have promised to address the resulting misuse of public funds by transforming the way their system works. Under the heading of ‘efficiency savings’, they have committed to transform practice from being ‘deficit’ to ‘strengths’ based as the route to bring about the transformation.

What the evidence tells us

We have set out elsewhere that the chaos of how the resource allocation system actually works is in complete contrast to the way public messaging says it works. It resutls in a ‘post code lottery’ of enormous proportions. This allows us to glimpse behind the facade to see how councils are actually spending their money. What difference does having more money to spend on individuals make?

In 2024/25, publicly available data on NHS Digital on spend on long term care and number of service users, allows us to discover the following

·      For older people, the top spending 10% of councils spent an average of £27.5K per person, nearly double the lowest spending 10% at £13.7K

·      It’s the same for working age people at £25.5K and £47.6K

What are the highest spending councils spending their money on compared to the lowest? Social care’s leaders claim that it is under-funding that is holding them back. If so, we must expect the highest spending councils to be leading the way. But are they?

A widely accepted measure of social care at its best is the least use of residential and nursing care. Residential and nursing costs on average three times more than supporting people at home whilst being the least independent option for the person.

·      For older people, 27.6% of people served by the lowest spending councils found themselves in residential and nursing care. For people served by the highest spending councils, the percentage was substantially more at 45%

·      For working age people, the figures are 11.2% and 14.3%

So if you happen to be served by a council with more money to spend, you are much more likely to find youself in institutional care.

There is also a major difference in how much support is provided to people in their own homes.

·      For older people, the highest spending councils spent an average of £15.7K per individual, over double the £7.6K of the lowest spending councils

·      For working age people, the figures were £38.8K and £21.5K

Conventional wisdom is that the more support provided at home, the greater the chances of preventing loss of living in one's own home through admission to institutional care. Prevention is key to financial sustainability.  But this is not happening. Despite spending very much more on support at home, the highest spending councils have far higher rate of placing people in institutional care.

This points to social care institutionalising people in their own homes no less than it does so by removing them to institutional care.

Why is this happening?

The evidence leads to two conclusions:

• Directors are right to believe that social care badly delivered creates dependency and demand

• The are wrong to claim their strategies to transform practice from bad to good are working.

Their strategies are rooted in the belief that responsibility for dominance of the ‘deficit’ based practices rests with practitioners making the wrong professional choices. Training and exhortation to practitioners is their answer.

But they are not a professional choice. They are the consequence of the requirements the system places on them. Spending is controlled by shaping need to the local budget, whatever its size relative to demand. This creates the race to establish 'eligibility' with devestating consequences:

• Whereas good practice calls for resources to be allocated to make lives the best they can be, the eligibility determination is rooted avoiding lives being the worst they can be.

  
  

• Whereas the currency of good practice is strengths and outcomes, for the system it is risk and deficits.

  
  

• Whereas good practice - and the Care Act - require the person to be empowered in how their needs are defined and so have ownership of the subsequent plan to meet them, the system requires the professionals to have absolute control.

The eligibility process requires practice that is deficit based and disempowering. These are the characteristics that it has long been known are instiutionalising. The empirical evidence could scarcely be clearer evidence.

It is an inherently institutionalising system. Whilst the system may co-incidentally meet a person's real needs appropriately, only the small number who have what it takes to manage their own support with a direct payment can be consistently relied upon to ensure resources make their lives as they should be. Only fundamental, systemic reform can make it the norm for all.