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The Care Act posed an existential threat to the way Government had successfully managed the tension between needs and resources for decades. Social care had long been seen as a serious financial risk, with demand believed to be bottomless. But the risk was eliminated by policy choices that ensured spending always remained within budget, regardless of its level relative to need, and with no need left unmet. Any noise to the contrary from the service user community and their representatives could be side-stepped. Budgets could be set each year in the knowledge that the previous year’s budget was sufficient to meet all needs, with only incremental changes, up or down required.
Political leaders were content for their heads to remain in the sand.
But political leaders showed no concern to find the year in which the budget was zero based, that is, when the cost of meeting all needs was established. This would be required to justify the belief that only incremental changes in subsequent years would keep budgets sufficient. Neither did they make any attempt to understand exactly what needs were being met. Political leaders were content to accept the gobbledegook offered them about ‘eligibility’. They accepted this was professional territory and beyond their ken. Political leaders were content for their heads to remain in the sand.
The Care Act 2014 seriously threatened to rock the boat. The Act said there must be a three stage process;
Needs must be identified against nine areas of wellbeing. There was broad consensus these areas comprehensively identified what any of us would regard as making for wellbeing. Councils must do so without regard to existing resources.
Councils must them decide which of them fall to being a legal duty to meet – regardless of the cost. It would be for the Secretary of State to set the threshold. It would be a minimum guarantee.
Councils were then given the power to meet any needs beyond that threshold. As it was a power, not a legal duty, councils would be legally secure if they in being transparent when they did not have the resources to meet needs.
The Act also required councils to be aware of the level of services to meet all needs in their community. The three stage process would end with the information essential to meet this requirement.
But it would mean political leaders being exposed to the true cost of all to have the wellbeing possible for them. The information would be in the public domain, and with that would come political pressure. It would also mean professionals having to completely change their modus operandi.
Resolving the dilemma
Government resolved the problem with a nod, nod, wink wink strategy.
Through the Statutory Guidance to the Act, they told councils they must not only deliver the Care Act, they must exceed it. It would not be enough simply to be aware of the size of budget required, but they must ensure ‘that the funding available to the local authority is sufficient to meet the needs of the entire local population’. Given such a budget, the power to meet need would become redundant. There would be no needs unmet. Consequently, the Statutory Guidance need make no mention of either the power to meet needs (other than in emergencies) or how to address unmet need. Neither would arise. The threshold for the legal duty to meet need could be defined by ‘eligibility’ criteria. Any need that did not meet the criteria would be met by advice, information or signposting to another service.
Thus the legal duty to meet need would be the total offer, not a minimum.
But this was, of course, nonsense. It was completely undeliverable. Councils cannot possibly set a budget guaranteed to meet any particular level of needs, let alone all needs. They rely to a significant degree on Government grant over which they have no control; Government controls how much local tax can be raised; the amount councils can collect in local taxes is highly variable; they have to compete with other services for resources within a somewhat messy process of negotiation.
Secondly, Government had also known, since 2008, that eligibility criteria are incapable of determining levels of spend and needs met. The Audit Commission reported great inequity between councils despite them having the same eligibility criteria. A parallel qualitative study found that the decisions about which needs were met was not determined by eligibility criteria, but by the ‘street level bureaucracy’ which made all the case-by-case decisions.
It was a nod and a wink to councils to carry on as they always had. Whatever budgets they set, their street level bureaucracies would continue to expand or contract ‘need’ to match them. Spend will continue to be to budget and there will continue to be no unmet need. Government helped further by saying the new eligibility criteria, despite wording that was completely different from the outgoing criteria, would result in the same level of spending as the outgoing criteria. So no need for zero base budgeting.
Councils got the message. They re-wrote their own glossy brochures using the language of the Care Act. They taught practitioners the new language and enthusiasms. And they allowed the ‘street level bureaucracies’ to continue their work.
The boat was steadied.
With the cat out of the bag, political and professional leaders will have to make a choice.
The consequences have been predictable;
Profession centric decision making leaves the vision of individuals having control over their services and lives as far away as ever.
The continuation of allocation of resources through greatest need means the vision of a shift toward prevention as the win-win of social care is also as far away as ever.
The level of inequity is ever greater. Whilst all councils say they meet the national eligibility criteria, once regional price differences and different age profiles of communities served are allowed for, the most generous councils spend 60% more per service user than the least. The facts are hidden in reports not made public in which council leaders say any disparity is due to factors beyond councils’ control.
Social care leaders have long known the system misuses money by inducing dependency. The highest spending councils achieve no better outcomes than any other. Ipsos Mori in 2017 found there was no relationship between needs being met and wellbeing.
With the cat out of the bag, political and professional leaders will have to make a choice. If they wish social care to remain rooted in resource preceding need, it will have to justify it transparently. It could no longer be delivered behind a veil.
On the other hand, they may support the campaign to introduce the principle that need precedes resource within a National Service. The Charter for the Right to Wellbeing would be its foundation.