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This month, I was privileged to be invited to address the AGM of the National Direct Payment Forum. These are the people who provide the support essential to the success of direct payments when used by people to manage their own support by employing their own staff.
The meeting had reflected already on the changing role of their services. It has been a change for the worse. In the 1990’s and the following decade the role was to support the creativity and user’s true ownership of their support. But the past decade has seen the role increasingly to closely monitor the person’s use of the money and reclaim as much as possible. The role has shifted from enabling to policing. This is taking place within the context of ever diminishing resources and size of the direct payments. Overall, the outcomes for direct payments recipients, whilst still overall better than for people with commissioned services, are reducing.
Now is the time for hard truths and serious debate.
The task I was given was to address the broader issues of the social care crisis. This is the context for what is happening in the direct payments field. Understanding the impact of the broader context is key to identifying the best strategy to reverse the decline.
I started by warning the meeting that I would not shy from making uncomfortable points. Now is the time for hard truths and serious debate. The following summarises the key points from what I had to say.
The widely held narrative about the social care crisis, created by councils, social care’s leaders, think tanks and academia, is that it is the result of under- funding following years of austerity. They urge a return to pre-austerity levels of funding.
But the evidence not only fails to support this narrative, it contradicts it.
Last year’s spend of £28BN was more or the less the same in real terms as the £18BN in 2010/11. Social care has been protected through austerity.
The pre-austerity levels of funding already left huge swathes of needs unmet. The Minister for Care, Paul Burstow, batted away claims from think tanks that £7BN more was needed
There is an astonishing 80% difference in the spend per service between the highest and lowest 10% of councils. Yet the annual survey of service users shows there is no difference in how much the support they receive improves their lives or gives them control.
In a system that generates dependency, people served by the councils who spend the most per service user are up to 50% more likely to end up in residential or nursing care. This is both the most costly and least independent form of care.
Furthermore, the highest spending councils pay providers 12% above their regional average older people and the lowest spending councils 19% below. The highest spending councils spend £1,049 per week on average and the lowest just £758
Social care is in a perpetual state of crisis - and its self-inflicted. The strategy chosen to reconcile spend and budget is the traditional one of meeting only needs that are a legal duty to meet – ‘eligible’ needs. This is a policy choice. It is neither a requirement of the legislation nor the result of underfunding, both of which councils claim. It’s a strategy that inevitably
results in ‘eligibility’ being determined at the point of intersection of local demand and local supply. The national eligibility criteria, used only to provide the language to describe eligibility decisions, give the appearance of a system that is fair, ordered and transparent. But the reality is a system that is random and chaotic.
Despite sector leaders’ ironic protestations to the contrary, the strategy has succeeded in protecting social care throughout austerity. But a Bob Dylan song had a line for it – success is but a failure, and failure is no success at all. The level of funding that has been protected started left a serious gap between needs and funding, a gap which has grown steadily year on year as demand has increased. The number of older people alone has grown by some 15%. It has further failed by creating a culture that has little regard for the human
experience – money and legal obligation define the world as seen by the system and its actors.
This is the context within which it is possible to make sense of the Bristol ‘Fair and Affordable’ policy. The system’s culture made it possible for the Council to believe it was both legally and morally sound to remove people from their own homes and place them in residential care if cheaper. It allowed them to believe that living in one’s own home does not meet any needs - it is nothing more than a ‘preference’. The Care Act does not require councils to meet mere preferences. Residential care will be more ‘cost effective’, benefitting both the tax payer and the individual whose needs for wellbeing will be fully met.
The brazenness is astonishing. No less astonishing is the disdain shown for the public and service users as consultees. The Council’s public consultation on the policy was a sham that they scarcely bothered to conceal. During the period of the consultation they spent £1.5M on a management consultancy to develop the policy, and appointed a hit squad of ten social workers to implement it. But, of course, that did not stop the council from claiming the policy had been ‘co-produced’.
Elaborate statements of good intentions go into the shop window that hides the truth about how social care really works.
A resistance campaign was brilliantly led by the Bristol Reclaiming Independent Living (BRIL), a disabled peoples organisation with the freedom that comes from not being funded by their Council. One of its activities was a well attended open meeting involving national groups. The meeting heard of three approaches to change.
The first was from Social Care Future, promoting their inarguable vision of everyone living in the place they call home with the people they love and doing the things they love. To the Council’s brazenness and cynicism can be added a remarkable inability to see any irony in them wanting to adopt this vision at the very time they were planning to implement a policy to remove people from their home. Yet that is precisely what they are doing. BRIL was invited to a Council workshop to plan implementation of the Social Care Future vision. BRIL’s representatives asked how the policy and resource implications of the new vision would
be addressed. The answer was clear and simple – they wouldn’t be. Bristol are thus on a path trailed by Wokingham. In January Wokingham’s top Committee proudly agreed a Charter based on the Social Care Future vision. But unlike a real charter, which commits the
powerful to sharing their power in defined ways, the Wokingham Charter does no such thing. It is nothing more than a statement of good intentions.
This, of course, is a well trodden path eagerly adopted by councils and social care’s leaders. TLAP’s Making It Real strategy is similarly a series of statements of good intentions. It was introduced in 2012 the wake of the failure of the personal budget strategy to make ‘it’ – personalisation – real. Some 12 years on, Making It Real has had no impact. Promising to end bad and replace it with good behaviour without addressing any of the factors that lead to the bad behaviour in the first place is a common human failing. Elaborate statements of good intentions go into the shop window that hides the truth about how social care really works.
The second idea was the National Independent Living Service (NILS) championed by the DPO movement. Its core idea is replacement of the Care Act with new legislation that would create a legal right to all the resources an individual requires. Just as the Social Care Future vision is inarguable, NILS would be an inarguable ideal. However, there is no prospect of it happening in any foreseeable future. It would mean social care not just jumping to the front of the queue for public money, but completely bypassing the queue. The case would have to be made for social care to be given all the resources it needs and then leave the rest – health, education, police etc etc – to fight over what’s left. No such case has been made. We will perhaps have to wait for a society that puts public wellbeing above private wealth and funds all public services adequately before such legislation could be considered.
The third idea was our Charter for the Right to Wellbeing. This is a four step approach designed to fully implement the Care Act;
Social worker and the person jointly identify all needs the person has to promote their wellbeing as defined by the Act – which is no different to Independent Living as defined by the United Nations. They must do so without regard to the available resource.
Resources allocated to individuals within a process whose purpose is to secure the greatest level of wellbeing for the greatest number of people within the available resource. The ‘greatest need’ test of the eligiblity system will be replaced with ‘greatest impact’. The underlying narrative of social care will shift from a negative – what’s the worst life can be - to a positive, what’s the best life can be.
All assessed needs not met to be aggregated to create publicly available reports about the gap between needs and resources.
Transparent political responsibility to close the gap between needs and resources, thus delivering the UN requirement to progressively realise the resources required for independent living.
The Charter is not risk free. The legal duty to meet need would be reduced to the minimum it was always intended to be. The majority of needs for wellbeing would be met under the Act’s statutory power, currently never used. Whilst the professional contribution can be guaranteed, the political response cannot be.
The most important contribution this group can make is in supporting councils to design and deliver the change to their assessment and commissioning practices that will create authentically person-centred services.
BRIL has decided to sit tight. It is a perfectly understandable response to the terrifying prospects they face. Bristol’s Mayor and lead member for social care told BRIL on the day the consultation ended that the Fair and Affordable policy would not go ahead. Within days, they had agreed to a budget for 2024/25 that contained the exact same policy but in even more draconian form. BRIL members are entitled to take the view that the best chance they have of protecting their support in the immediate future lies in the status quo. During the course of our support to BRIL, we used the Freedom of Information Act to find out that Devon – upon whose ‘success’ in delivering a Fair and Affordable policy since 2015 Bristol said they followed – still have 88 people supported at a cost above residential care. That is about 1% of Devon’s service user population. They are likely to be the most obdurate and determined of those targeted by the policy not to be intimidated. If Bristol has the same ‘success’ as Devon, it will reduce the number supported at home above the cost of residential care by about three quarters. It may well be that BRIL members are the type of people most likely to be in the remaining quarter.
In summary, I expressed the hope that the Forum and Campaign for Real Care would have more dialogue and work together in the face of what is already a bad situation set to progressively worsen. A standstill budget with increasing demand is a recipe for continuing decline.
The Campaign anticipates that under the Charter for the Right to Wellbeing, the people the Forum supports could look forward to being restored to their previous position as exemplars of social care at its best and therefore leaders. However, it would not be on the basis that every service user can function in the same way. Nor would it be on the premise that it is always cheaper. Those were the two promises the Independent Living Movement made in the early 1990’s that persuaded successive governments to back them with legislation
and policy. Neither promise has been fulfilled. By 2010, this group accounted for 7% of service users, but 13% of the budget.
Whilst it may well be that the numbers can rise above current levels to some degree, all the evidence – and reason – says the majority of people will continue to rely on commissioned services. The most important contribution this group can make is in supporting councils to design and deliver the change to their assessment and commissioning practices that will create authentically person-centred services. Direct payment recipients know how to identify their own needs and make the best possible use of resources to meet them. These are exactly the professional requirements the Charter to the Right to Wellbeing will demand. It will mean ceasing to claim to replace commissioned services, instead they will become the enablers of the change of commissioned services.