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Arguably the single most important concept in social care is eligibility. Councils see their task as meeting eligible needs. Eligibility is how they decide which needs for on-going support are worthy of public funding and which are not. It determines what support people are offered. Government policy says the eligibility process is carried out fairly, to national standards and in a way that ensures people get the support that is right for them.
But nothing could be further from the truth, and Government has all the information to know. The following explains why.
1. In 2015, the Care Act presented the Government with the opportunity to right a long standing wrong – the ‘post code lottery’. In 2011, the Dilnot Commission, set up to address the funding of social care, reported how they found people with ‘similar needs receiving very different levels of provision’.
2. The eligibility policy of the time was held to blame. Fair Access to Care Services (FACS) set out four levels of priority – critical, substantial, medium and low. It was for each council to decide how many bands they would accept as ‘eligible’. The answer to the post code lottery would be to replace FACS with a single National Eligibility Criteria (NEC).
But Government knew that changing the criteria would not make the slightest difference
It had been known since 2008 that FACS played no part in how councils decided if a need was 'eligible'. The Audit Commission produced a report which showed large differences in spending levels between councils that had exactly the same number of bands they said were 'eligible'.
Alongside that, the Commission for Social Care Inspections – which preceded the Care Quality Commission – produced a report into what happens on the ground. It showed how the eligibility decisions were actually being made. It was through what they called the ‘street level bureaucracies’. These are the social workers, and they work to the managers who allocate the resources and control the budgets. The street level bureaucrats didnt apply the formal rules becuase they didnt work. They made their own rules.
This was confirmed in 2013 in an exercise carried out for Government by academics. In test condition, social workers from around the country were asked to rate the priority of a number of case scenarios. There were major variations between them. But crucially, not between social workers from the same council. This showed how it was each council’s local policies that determined whether social workers believed a need was ‘eligible’.
In 2008 there was a lot of variation in how many FACS bands councils treated as ‘eligible’. But by 2015 all but three councils said they were meeting critical and substantial bands only. Yet still the post code lottery persisted.
The three councils that were not critical and substantial were critical only. They said they would need more money to make the adjustment to the new national criteria. Government commissioned research to establish if that was the case. After a year, the research concluded these three councils were not providing any lower level of service than any other council. In some instances they actually provided more.
Government's own Impact Assessment of the proposed change from FACS to NEC said the change would result in a ‘threshold that describes a level that can maintain current practice'. And so Government did not need to provide new money for the change from FACS to NEC. Nor was any money moved between councils. It was a clear case of steady as she goes. There must be no change in direction,
The street level bureaucrats using the wording of the national criteria to describe their eligibility decisions served to give an impression of consistency, however misleading.
3. So, in 2015, Government had all the information at its fingertips to know that changing the criteria would make not the slightest difference to the post code lottery.
4. There is, of course no reason why Government would choose inequity. But, equally
there is a powerful reason why Government would not want to take the action required to eliminate the inequity.
5. The street level bureaucracies, howsoever they did it, were meeting political aims. Spending was always as close to budget as made no difference. And, with a need being a need only if there was resource to meet it, a very tight lid was kept on demand.
6. These are the 'current practices' that Government had no intention of losing. And it has worked. Over the past five years, spending has been within 1% of budgets; all needs councils deem worthy of public funding are met; the system believes there is no unmet need. It's a triple whammy for governments. Estimates by the think tanks of a large funding gap, based as they are on the false premise of social care being a rational, planned economy, fall on deaf ears.
8. But the wrong of the inequity pales against the damage of the further consequences. The profession centric and oppressive practices required to calibrate need to the budget are the very practices that social care's leaders know lead to the worst outcomes. They create crises and dependency meaning misuse of resources; they give service users the worst experiences as they take control over their lives. They are the practices Directors have been promising for years to eradicate and replace with ‘strengths based’ and ‘person centred’ practices.
9. It is only the small minority who have what it takes to escape the mainstream system by managing their own support with a cash payment who can be relied on to consistently know how to make the best use of public money. And this group of people are now facing increasing challenges to maintain support at the levels they need.
Not until Government, Local Authorities and social care’s leaders accept the sham and hypocrisy of the eligibility regime will social care be able to find a realistic path toward a vision that makes the best use of public resources to make the lives of older and disabled people they best they can be.