The hegemonic mindset keeping social care trapped as a failing service

Hegemony is defined as a way of thinking that holds power over people. But it does so through volition. Whatever the idea behind the thinking, it is widely accepted as based on truisms, simple common sense to which all should subscribe.

There is a mindset amongst the professionals employed by councils that matches this definition. They believe that society and its leaders have little interest in, and place no priority on, older and disabled people in need of care and support. They believe society has no interest in the service they exist to provide. Only under threat of the law will political leaders provide resources.

The professionals have a strategy to make this work. They interpret the law in a way that obliges the political system to provide the resources to meet every need that they, the professionals, identify. Such needs are called ‘eligible’.

Political leaders accept this position, but on certain conditions. The deal is that professionals pledge not to abuse the power this gives them. Only authentic need, not mere wants, will count. Professionals also pledge to be fair and transparent in deciding what counts as a need.  They will work to national eligibility criteria.

It works. All needs that professionals have declared ‘eligible’ are met. The Association of Directors of Adult Social Services reports that over the past 6 years, spend has been within 1% of budget

Both strategic and operational professionals thus have a powerful sense of moral purpose. It even survives the irony of having to be adversarial with the people they serve when, as individuals, they make demands on the budgets the professionals feel morally obliged to protect.

The downsides

A major problem with a hegemonic belief system is that people cannot see outside of it. It is difficult to contemplate reasons why it may not be right. But the evidence of the downsides of this strategy are great. They far outweig its benefits. They are in plain sight.

1.   There is a snag in the deal between professionals and politicians. Whilst the politicians are obliged to provide the resources to meet all ‘eligible’ needs, the professionals have an equal legal obligation to spend within whatever budget they happen to be given. Whatever the official eligibility criteria may say, the cliff edge over which a need becomes a want and disappears must move to wherever the budget set by the politicians dictates. Whilst the deal may appear to have given professionals the whip hand, it is actually held by the politicians.

2.   The Local Government Association produces annual reports for councils (on a confidential basis but secured through the Freedom of Information Act) on their use of resources. They include what is arguably the best measure of equity, the average spend per person served. If all councils followed national eligibility criteria we would expect spend per service user clustered around an average. But the LGA reports show this is not the case. All councils meet all needs deemed ’eligible’ and only needs deemed ‘eligible’. Yet the LGA report an astonishing difference in the region of 70% between the highest and lowest 10% of councils. (Even this is an under-estimate given the methodology used by the LGA^[1].)

3.   But the inequity pales into insignificance against the most damning of the downsides. The eligibility process has defeated every strategy over the past three decades to transform social care from a failing service to one fit for a modern society. The eligibility process makes impossible four core tenets of what has long been known is required.

• Resources must be matched to the uniqueness of individual need. When every need that has been identified is a legal obligation to meet and a demand on the budget, ensuring the resulting spend is to budget requires demand to be in the form of a controllable flow.  That requires need to bestandardised, thus denying individuality.

• The person must have agency in how their needs are defined in order to retain control of their life. Deeming a need ‘eligible is committing the council to spend. Ensuring the rsulting spend is to budget requires professionals to have unilateral control. Decisions are made behind closed doors.

• Resources must be allocated to secure greatest impact in making lives the best they can be. The high stakes nature of the needs-wants cliff edge results in resources being allocated on the basis of greatest need, not greatest impact. The strategic aim is not to use resources to make lives the best they can be, but avoid them being the worst they can be.

• Support should be designed around individual aspirations and strengths. Knowing what will have the greatest impact requires understanding the person’s aspirations and strengths. Greatest need is rooted in risks and deficits.

It is a great irony that the impact of these practices on the misuse of public funds is exactly as professional leaders would predict. This is addressed in detail in The (Real) State of Social Care.

4.   Calibrating eligibility to the available resource means, as surely as night follows day, that the system never has any information about unmet need. It simply cannot be allowed to exist. National and local political leaders are entitled to say the system is adequately funded to meet all need. Professional leaders are shooting themselves in the foot.

Prospects for change

The Charter for the Right to Wellbeing sets out an alternative. Social care should replicate the political-professional dynamic that drives the NHS. The legal duty to meet need would be no more than a minimum guaranteed safety net that ensures survival. Needs for wellbeing in the round would be met using the Care Act's statutory power. Professionals will thus be able to identify all needs following known best practices. The political system will be exposed to its responsibility to provide the funds for all to experience a life of wellbeing. Unmet need in social care would deliver the same function as waiting times in health care.

Whether to make the change is in the first place a political, not professional, choice. Political leaders will, however, need to be mindful of the professional response and what their advice is likely to be. It will range from outright rejection to enthusiastic support.

• It is within human nature to defend. That much is to be expected. But an idea being held hegemonically does not in itself make the idea wrong. There will be professionals who will continue to believe that legal obligation is necessary to lever money from a society that places little value on the lives of its older and disabled citizens. They will be entitled to point to the success of having protected social care budgets throughout the age of perma-austerity, notwithstanding it is at a level that has always left large swathes of needs unmet. They may fear that political leaders will believe public responsibility ends with enabling mere survival and set policy accordingly. They will also find support for the status quo from advocates who know how to beat the system to secure better support in individual cases, notwithstanding their success is at the expense of others in the zero sum game that ensures spend is always to budget.

• There will, however, also be professionals who will embrace the liberation the Charter would bring. Practitioners will relish being able to practice according to their values and ethics. They will relish becoming authentic advocates for the people they serve and being the source of information about need that informs budget setting and strategic commissioning.

• Strategic professionals whose job is to secure budgets will similarly be liberated to act as authentic advocates. They will cease basing their case on fear of legal penalty against the will of a reluctant public and its leaders They will make the positive case of making the lives of their fellow citizens the best they can be. They will leave behind the obscure, legalistic narrative to describe social care and replace it with a narrative the public will be able to relate to and engage with. They will be free to acknowledge they may have been the very source of the negative public perception of social care. The reluctance to fund having been a self fulfilling prophecy.

Summary

Any challenge to a hegemonic mindset is challenging. It is even more so when held within an authentic sense of public service and moral purpose. A key objective of the Campaign is to support professionals to get beyond hegemony and raise debate.

^[1] The LGA understate the difference becuase they exclude the top and bottom 10% on the basis they may be outliers. However, there are no outliers (other than Isles of Scilly). The (real) state of social care puts the difference close to double.