There was policy among the politics in Wednesday’s Queen’s speech, although not all of it was necessarily pulling in the same direction. For political consumption the Government is offering a new clamp down on the rights of non-UK nationals to access our NHS services. Let’s see if it proves more consequential, or electorally satisfying, than the many clamp downs that have preceded it. On the policy side, the government is taking important steps to reform social care, capping individual liability for some costs, introducing new rights and prioritising early intervention support. The social care sector will need to grow and change radically in order to meet the aspirations behind the proposals. Whether this will be helped or hindered by restricting the ability of migrant social care workers – on whom the sector has been highly dependent – to access health services while in the UK has yet to be seen.
The kindest interpretation of events is that the Coalition is deliberately underlining that the way we’ve expanded our caring capacity as a society in recent years is unsustainable, fiscally and socially. We cannot continue to rely on professional services, often offering low-pay, low-prestige jobs, intervening at points of crisis or severe infirmity and offering relationships between carer and cared-for that are so tightly rationed that care itself struggles to keep a foothold. A high-quality care sector can only be part of the solution to living well in a silver society. A much larger role needs to be played in future by softer interventions that maintain wellbeing, respect independence and nurture social-interdependence across the life-course. With its stress on reducing people’s dependency on formal care services through earlier intervention, the Care Bill is a useful step in the right direction. But as a pamphlet we published this week argues, its attachment to needs rather than strengths may ultimately perpetuate a system in which rationing around individual thresholds distorts our overall social investment and can create perverse individual incentives and unfair outcomes.
We believe that the Bill should go further. At the same time, we believe that the onus for change doesn’t rest exclusively with the Government, or even local government. How we function as a society will need to change as who we are as a society changes. Work in support of the National Dementia Strategy is instructive and important in this respect, reframing a medical condition as a social challenge with implications for communities and employers, as well as health professionals and care services. In a paper that we published last year, Craig Berry struck some important cautionary notes; yet many of the opportunities for improving the lives of our older citizens lie outside of traditional services. For example, we are currently working with Asda to explore how they could operate in ways that generate greater social value. The amount of store space that will be needed for retail is falling, so what other functions could the store spaces provide? How could stores like Asda, in partnership with community groups or mainstream public services, create opportunities for isolated older people to come together, share skills with each other or with younger people, perhaps learning how to pool personal budgets in order to access care that they would value? We have also been working with the Scottish Environment Protection Agency and Scottish Natural Heritage to look at the role of access to high quality natural environments in supporting health and wellbeing throughout the life course. The importance of green space for healthy childhoods is now widely recognised, but designing healthy green space for active older communities is just as important, yet receives relatively little practical attention.
It’s unfortunate to see our older population routinely referred to as a burden, a timebomb or – more recently – the sharpest teeth in the LGA’s jaws of doom, threatening imminent financial breakdown. A whole-place, strengths-based approach doesn’t substitute fantasy for reality, but it is useful because it puts all of us in the frame.
Paul Buddery is Partner at RSA 2020 Public Services. He tweets at @buddypb
35 social care professionals, local authority representatives and policymakers discussed reforms to the draft Care and Support Bill at an event hosted by the RSA’s 2020 Public Services Hub. Alex Fox FRSA, CEO of Shared Lives Plus, guest blogs about the event and Bill.
There can be few people unaware that there are NHS reforms afoot in the UK. Yet few are aware that the most sweeping social care reforms in post-war history are now taking place, with existing ‘poor-law’ based social care law to be replaced by new legislation outlined in the draft Care and Support Bill.
The Care and Support White Paper which preceded the Bill set out a new vision for the ‘personalisation’ of social care. This takes the idea of individuals having an individual choice of service and control over their lives as read, but recognises that even a well-funded, well-tailored service does not always add up to a good life, particularly if your support needs are social rather than entirely physical. For instance, taking a cash Direct Payment in lieu of a service to hire and manage a team of Personal Assistants can be the ideal solution for meeting physical support needs while staying in charge of one’s own life. One individual who now manages his own care said, “When I got my disability I was stuck in hospital whilst services argued over paying for adaptations to my house.” Yet if someone’s challenges involve isolation or social exclusion, the solutions are likely to lie partly in that individual’s unpaid relationships with families, friends and others in their community.
The reorganisation of social care around promoting wellbeing is a radical and welcome vision. But there is concern that the draft Care and Support Bill will not fully enable this vision in practice. Five pioneering community support organisations -Community Catalysts, In Control, Inclusion North, Inclusive Neighbourhoods, Partners in Policymaking, Shared Lives Plus, as well as a leading Director of Adult Services – have argued in a briefing on the draft Care & Support Bill that the Bill needs set out a different route into – and out of – social care to achieve an affordable, more empowering and more successful care system.
In particular, the care organisations argue that eligibility tests should not be the first conversation which people have when they encounter social care. Instead, they should be offered support with life-planning as the first intervention. These personal planning discussions would look first at the individual’s strengths and skills, rather than considering only their needs; then at their existing supportive relationships with family, friends and the wider community; and lastly at services. The wellbeing principle should be developed to set out in plain English a minimum acceptable level of wellbeing to replace the current Fair Access to Care Services (FACS) eligibility criteria.
The recommendations are based on the care organisations’ experience of how people are changing lives and communities for the better, often with less money than has been spent on traditional services. At a recent roundtable hosted by the RSA’s 2020 Public Services Hub and chaired by Paul Burstow MP, who currently chairs the Joint Committee scrutinising the draft Care and Support Bill, one participant said that the current system intends to be empowering but “drags us back” into a deficit-focused model and “dependency culture”. In contrast, when disabled people and family carers themselves are involved in explaining support options to others, there can be a more honest conversation. A parent said, “When I had my daughter in the 1970s it felt like I’d fallen down a rabbit hole into a world I didn’t know existed. I had no support strategies and was battling every day to get simple things. Other local parents were holding on to what they knew and were wary of change.”
Likewise, Partners in Policymaking runs citizen leadership courses for disabled individuals and the parents of disabled sons and daughters, and brings families together for peer support and to influence decision makers. Before the courses participants say that they would often “just talk about their problems, not about what would make things better”. After completing the courses, many people get jobs and some set up groups or social enterprises to tackle the challenges they have experienced: “I would have been one of those parents who wrapped my daughter in cotton wool, but I started to see her as a citizen of this world with the same rights as others and now she’s done two degrees. We learnt to ask for what was needed, not what was on offer and we built a community. One young man would have gone into residential care when his Mum went into hospital, but with support from the network he is still living at home after seven months.”
Moving away from the mindset of “These services are what we have on offer” towards “What would you see as a good life and how can you move towards living it?” represents a huge culture change, particularly at a time when many services are in crisis mode. Mechanism changes such as personal budgets, implemented in the aim of personalising care, have not always created change of this kind. Though some councils, providers and professionals have implemented personal budgets, these are still used to buy the same old services staffed by the same people. In contrast, two social entrepreneurs described how they had built upon the skills and insights they had gained working within public services to identify a gap in current provision, going on to set up their own small enterprise which provides transition support for young disabled adults which is tailored to their goals in life. They are just one of around 800 micro-enterprises known to the partner organisations.
A new social care law cannot legislate for culture change of this kind. But, while Direct Payments remained little used for a decade after they were introduced into law, the cultural shift towards individual control which eventually followed them would not have happened without the original legislative change.
Some councils are already trying to make a change of this kind, even within the present system, with FACS tests replaced by questions which could be used to define acceptable wellbeing such as: Are you safe? Can you live with dignity? Do you rely upon services for personal care? Are you connected to those around you? Are you able to be an active citizen in your community? A personal planning approach which helps people to find, recognise and use all kinds of resources and relationships, including family care, community groups and new links to people in similar situations, will often find ways of improving wellbeing without relying upon services.
However, developing a different approach to care with local spending cuts of up to 40 per cent is clearly a challenge: “we are reneging on the welfare state commitment made in the ’40s, with no evidence that the taxpayer will step up. So we either abandon those goals, put our hands in our pockets, or take collective responsibility and have a new public discourse on care.” Or as one council representative said, “it’s not ‘doing more with less’, it’s doing ‘different’. We need to remember that we are often the minority partner in the provision of care and to be careful about where we are putting our big feet. The economy of regard doesn’t function in ways in which we always understand.”