THE THINK TANKS – HELP OR HINDRANCE IN THE SEARCH FOR CHANGE?

Every year since 2019, the Kings Fund analyses the publicly available data to analyse what is happening in adult social care. Its Social Care 360 reports are respected by sector leaders and policy makers. This year an upbeat note was struck:

●     Whilst real terms spending has increased since 2015/16 by 30%, it had until 2023/24 been absorbed by increases in fees paid to providers. However, more recently there has also been an increase in numbers of people served, now 2% more than in 2015/16. Although less than the growth expected in demand from demographic change, it is a positive move.

●     The Kings Fund notes that the increases are related to additional Government funding. It rose from £2.3b in 2022/23 to £3.9b in 2023/24 and then £5b in 2024/25. Money set aside by the Conservative government to introduce a cap on charging was pumped into the system when the current government abandoned that plan.

A trend, or one-off?

The Kings Fund says, however, ‘it is by no means clear that the trend will continue’. This is the key question, and there is evidence that addresses it. However, it is evidence that challenges two defining assumptions that underpin the public narrative created by councils and the provider community and which the Kings Fund uncritically accepts.

Those assumptions are:

1.      eligibility of need is determined by the official national criteria. The solution to the problem of unmet need is to widen the criteria and increase funding accordingly

2.      there is no profit beyond that which is a reasonable return, with provider financial viability dependent on requiring self funders  to pay 40% more than publicly funded service recipients.

However, the evidence contradicts both positions.

●     There is huge variation in the cost of meeting needs deemed by councils to be ‘eligible’. Given that only ‘eligible’ needs are met and that all ‘eligible’ needs must be met, councils can stay in budget only by matching ‘eligibility’ to suit their budgets. We set this case out more fully here.

●     The source of information used by the Kings Fund about the scale of profit is a consultancy commissioned by the providers themselves. They, of course, have a commercial interest in the outcome. Exposure of profit that might be considered ‘excess’ would not be in their interests. But the Kings Fund is paying no heed to research from at least three respected economic think tanks – the New Economics Foundation; the Centre for Health and Public Interest; the Institute of Public Policy Research. They each identify significant levels of excess profit and therefore extraction of public funds from public service. We address this issue more fully here.

Success – or failure?

The increase in spending is real. Sector leaders can claim a measure of success for the strategy they use to secure funding. It rests on them needing funding to meet legal obligations, on the premise that those legal obligations are determined by the national eligibility criteria. But, two problems must be addressed before that success can be judged sufficient:

1.      The first problem becomes self evident once it has been accepted that eligibility is not determined by the national criteria but is calibrated to the local budget relative to local demand. A system that denies the existence of any need for which it has no resource can never know how much resource it actually requires.

2.      The second problem is that calibrating need to the available resource requires practitioners to deliver the very practices that sector leaders know results in the creation of dependency and thus of demand. Directors up and down the country have been promising year on year ‘efficiency savings’ through transformation of practices. The practices that promote dependency are to be replaced with the practices that make the best use of resources to make lives the best they can be. But transformation, by its very nature, is a one-off event. Once the workforce has learned the new practices, all assessments and reviews from that point will be subject to those practices. The perpetual re-appearance of ‘transformation’ is, de facto, evidence of its failure. Here we set out the evidence that shows how the system institutionalises people and at what cost. There is research to suggest that whilst the changes in practice have been intensively sought managerially, it is not matched by delivery in practice. Researchers are left searching for the key to change.

It continues to be the case that only the small number who can escape the system with a direct payment to authentically self-direct can consistently know how to make best use of public resources to make their lives the best they can be. They too are increasingly under threat as councils seek to impose more the assumptions that underpin the mainstream on them.

Perhaps the shock of what the lockdown of 2019-21 showed the nation about the state of social care led its political leaders to embark on a rescue mission. But that would be a one-off. It’s a motivation that will not be sustained. 

The change required

With no information about the level of funding required, the sector relies on academic projections from the think tanks to make the case for funding. The Health Foundation is to the fore. However, the think tanks also have no real time information either. The methodology they employ is to pick a point in time in the past as the base when it is assumed funding levels were correct. The Health Foundation takes the pre-austerity year of 2009/10. Projections of funding requirements are then calculated by data on demographic change since the base point and into the future.

But the fatal flaw is in the assumption that the base point was correct     . Because councils have always calibrated need to their budgets, no such point in time has ever existed. It was certainly not the case in 2009/10. At that time, the Kings Fund was estimating it would require £7BN, a 50% uplift, to meet all need while the sector was blaming under-funding for failure to deliver the personalisation agenda.

Until the system identifies need against a vision of how life should be, regardless of the available resource, it will neither be possible to implement the best practices that makes best use of the resource available, nor will it be possible to know how much funding is required.

Making best use of the resource available now and knowing the scale of the funding gap between needs and resources are surely the two essential pre-conditions to begin movement toward sufficiency of funding.

We call upon the think tanks to engage with the evidence above and reflect on whether they need to adjust their analyses if they are to contribute to the real and sustainable change all agree is required.