Can Local Authorities deliver the Prime Minister's vision?

The Prime Minister has made clear his vision for a national care service built on NHS principles. It will have three defining characteristics:

1.      be free at the point of need

2.      be person centred

3.      a system that puts people before profit.

The first has gained immediate public attention. It’s the most straightforward to understand. It’s also, in terms of policy, the easiest to address. It’s simply a matter of arithmetic to identify the cost, to be followed by the political fight as to whether the cost is justified and where the money will come from. The PM will hope to have spiked opposition by restricting the announcement to older people which will be paid for by ending the triple lock, for which there is already a substantial body of support.

Making social care free is a matter of funding reform. The system itself can simply stand by, hope it goes well and wait to be the beneficiary. But creating a person centred system that puts people before profit is a different kettle of fish. That will require system reform.

System reform – the sector’s perspective

Sector leaders, however, adopt the same passive position as for funding reform. Directors, having committed for over a dozen years to training of practitioners to transform their practice to being strengths based and person centred, say that all is required now is for higher levels funding so support plans are sufficiently well resourced.

But this runs into rather obvious difficulties:

1.      With the Care Act acknowledged as pioneering legislation through creation of the wellbeing principle, all councils say they are already meeting all needs the Care Act requires them to meet.

2.      There is actually no logic to says that all of a person’s needs, or even a given percentage, must be met before the support that is offered is person centred.

To this can be added the less well known, but no less compelling, contradiction of the enormity of post code lottery in how much councils spend per person at the same time as saying they are meeting all needs the Care Act requires, and only needs the Care Act requires. There is no suggestion that the highest spending councils are any more able to escape the strictures of financial pressures than the lowest spending.  

To these contradictions can be added sector leaders’ failure to acknowledge the issue of excess profit extracting public funds from the system. The ADASS Annual Budget Survey refers only to providers being cash strapped and needing councils to pay higher prices.

Chicanery, or something else?

The question arises as to why Directors are behaving in this way. And why are the political leaders to whom they are accountable silent and therefore complicit? Is this knowing chicanery, or something else?

There is both soft and hard evidence to inform an understanding.

The soft evidence is what we actually see in their behaviour. The Campaign for Real Care has a long history of seeking to engage Directors and their senior teams and the Councillors to whom they are accountable in this agenda. Despite occasional glimpses of openness to discussion, the contacts consistently result in absolute denial of the existence of the contradictions. Resistance and denial increase when presented with evidence of how public money is being systematically misused by what appears to be systemic creation of demand through crises and high needs.

The door to discussion is slammed shut. Whether it is anger or anxiety or both, the emotional content is high and the quality of argument low.

The hard evidence comes from the history of how needs and resources are reconciled through the eligibility process.

The history of eligibility

In 1948 responsibility for the care of older and disabled people transferred from Poor Law institutions to local authorities. But the result was not good – provision was meagre. A campaigning Labour MP, Alf Morris, believed the solution would be to place councils under a legal obligation to meet needs. In 1970, he steered a private members Bill through Parliament that brought it into law.

The idea took hold. It began to shape how the system worked. To this day needs for on-going care are only met if there is a legal duty to do so. Just as the idea has lived on, so the belief which drove the idea has become hardwired into the culture:

society will only make resources available for the care and support of its older and disabled citizens under legal duress

The consequences today

The result is a highly charged negative narrative that professionals use to secure resources. It is, however, carried out with strong conviction and clear moral purpose:

·      Directors’ moral purpose is to secure the best budget they can. They do so by making a case rooted in the need for the council to meet its legal obligations or face judicial redress. 

·      Social workers’ moral purpose is to secure the best level of support they can for their clients. They do so by making the case in terms of risk and dependency, the currency used by the system for the high stakes, in-out, cliff edge eligibility decision.

·      Caught between these two levels are the resource allocators with responsibility to ensure spend is within budget. Their moral purpose is to share resources as fairly as they can between the people they are responsible for.

The three levels support one another within a mutually reinforcing siege mentality which over the decades has become normalised. The people delivering the system are doing the best they can within a hostile environment that places no priority on the service they are delivering.

Implications for the PM’s vision

The bedrock of a social care system is the process that identifies ‘need’. For the system to be person centred, the process that identifies need must be person centred. This requires the uniqueness of each individual’s lived experience of their need to be embraced. This is incompatible with need being standardised which is required to create the controllable flow to ensure spend is to budget. The system must be able to accept the identification of need exceeding the available resource. Just as the NHS has waiting times that measure the gap between needs and resources, so must social care be able to acknowledge unmet need.

Given that the eligibility system is indispensable to the way local democracy secures resources through local taxation, and given that the eligibility system must be replaced to deliver a person centred system, social care must be funded from general, not local, taxation.

Structural implications

The question then arises as to the structural implications. Delivery will continue to need to be local, but will local authorities still be the right vehicle? Social care will be funded on the same terms as the NHS. Care Trusts deliver locally. Will this model best serve social care?

Local delivery in social care will need to have a much greater engagement with local communities than is required in health care. Needs for care and support arise in the context of local factors to a degree that is not the case in health care. The delivery vehicles in social care will have to have close and dynamic relationships with community representatives in order to understand need and how best to meet it. Representatives of disabled and older people will need to be part of decision making constitutions.

This does not preclude local authorities from being the delivery vehicle. However, the need to be engaged with, to the extent of being part of, their local community represents an existential challenge.  The siege mentality calls for the very opposite. Councils need to keep a very clear distance from the people they serve and the communities in which they live. Efforts at ‘co-production’ reflect an awareness of the situation, but are rarely experienced by people and their communities as anything other than tokenistic.