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 into how councils are spending their money. What difference does having more money to spend on individuals make?

In 2023/24, publicly available data on NHS Digital on spend on long term care and number of service users, allows us to discover the following

·      For working age people, the top spending 10% of councils spent an average of £47.2K per person, more than double the lowest spending 10% at £22.8K

·      It’s the same for older people at £13.3K and £26.8K

The question is, 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 surely can 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. It is the least independent option for the person and costs taxpayers the most.

·      For older people, 30.9% 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 43.2%

·      For working age people, the figures are 12.8% and 17%

So if you happen to be served by a council with more money to spend, you are much more likely to end up 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 £16.2K per individual, well over double the £7.7K of the lowest spending councils

·      For working age people, the figures were £39.9K and £18.5K

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 makes people dependent.  But they are wrong to believe their strategies are bringing about the badly needed change.

Directors’ strategies are rooted in the belief that responsibility for dominance of all the bad, ‘deficit’ based practices belongs to practitioners through the professional choices they make. Training and exhortation to practitioners is their answer.

But it’s a strategy that fails. Those practices are not a professional choice. They are the inevitable consequence of managerial control of professionals’ practice. And managerial control of practice is the inevitable consequence of a system that controls spending by calibrating need to whatever the local budget happens to be. And calibrating need to the local budget is the inevitable consequence of a policy of only meeting needs if under a legal duty to do so.

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.