In an entry a couple of weeks ago, I identified three problems with the current way in which an individual’s needs are assessed, then their ability to pay, and then their social care entitlement converted into a cash amount, which they are helped to spend. I suggested that, even done well, the system had these problems:
- The assessment of your needs is based on you proving how bad things are. You might even have to wait for things to get worse before you become eligible for expensive support, when making cheaper, preventative support available would have been much more cost-effective.
- The addition of extra assessment and planning stages to the existing system, in order to convert your needs into an appropriate cash personal budget, has added bureaucracy. There is actually more gatekeeping than ever in some areas.
- The process focuses everyone on the money, which makes it harder to focus on outcomes and being creative.
I promised to think up some solutions to those problems, and asked you for yours.
The comments you were kind enough to post were very interesting. There was some consensus around the problems. No one believes that giving people the chance to control the money that is spent on them is the wrong aim, but lots of people would like it to be simpler, quicker and fairer to get to that amount of money, with fewer restrictions on what it is spent on. Several people feel that there is no way round the need for a RAS type system, and we should accept that reality and focus on making it work. If you put identifying the service first, you’ve returned to the old system; if you put identifying the budget first, you need to base that budget on costings based on a range of likely services. Few contributors, I felt, could articulate a practical third way.
Resource allocation systems build in two opportunities for professionals to exert control: first in setting an indicative amount, then in signing off (or not) the final budget. If it is never going to be possible for the state to relinquish budget sign-off completely, how could that control at least be eroded or tempered, without leading to bankrupt councils?
At a corporate level, council finance directors cannot relinquish overall control of budgets: it’s their job not to overspend. There is a tension between this need to exert control at a population level and the desire to relinquish budgetary control at the individual level. We could reduce that tension in a couple of ways:
First, and least likely, we could give council finance directors a breathing space where, if they can produce balanced budgets over five years, their budgets can be guaranteed for that period. This would allow councils to invest in prevention and to look more kindly on individuals who need to invest in non-traditional interventions which might prevent greater need later on. It’s hard to imagine this happening. The evidence base for many preventative services is weak and the government would need to find money up front and underwrite the losses if council’s plans didn’t work out.
Secondly, we could help people who use services act a little more like finance directors, through devolving spending power not only down to individuals (which puts me in the role of consumer, rather than commissioner), but also to groups and communities who would have the ability to invest to save on a smaller scale, taking risks such as investment in prevention, which are perhaps more manageable than the risks associated with council-wide investment. People who chose to take part would agree to spend their budgets collaboratively, aiming to meet their own needs but also to achieve outcomes for others. In return they would have access to the support of the group, which could include a shared emergency fund and the contributions from volunteers and families which a health community group can often bring in. Groups which were successful in bringing down costs whilst achieving outcomes could be given greater freedom and the opportunity invite more personal budget holding members. This is, of course, localism/ Big Society thinking and brings its own risks, not to mention public scepticism, but community budgeting ideas such as those espoused by the Stamford Forum are well worth exploring.
The suggestions above would not address the first and more fundamental problem I outlined at the start of this entry, which is that you have to wait until things are bad enough, and then prove it, before accessing new support. I believe the solution to this problem is to assess the individual’s direction of travel, not just a snapshot of their current problems. How about an assessment which looked at the next 12 months of someone’s life, for instance? Where are they now, but also, where are they expected to be? If the answer is, “okayish now, but likely to be in critical need of services in a year’s time”, then the person is entitled to a service now, even if, under the current system, s/he would be miles away from meeting the “critical need” eligibility criteria. The bad news is that councils would suddenly need to fund services for people who wouldn’t currently be entitled to a share of their pitifully small budgets. And no one has a crystal ball, so assessments would have to take an educated guess at someone’s future wellbeing, by analysing the risk factors in their lives. This would require new assessment tools, drawing on recent work on predictive risk analysis and the use of psychometric approaches which can draw robust data about wellbeing from fairly short self-assessment questionaires.
The good news for councils would be that people newly entitled to support, would be in need of cheaper, preventative services, not expensive crisis services. They would be encouraged to think in terms of investing to save and preventing future dependency. Providing that preventative services were effective, savings would be realised on crisis services within a fairly short period of time. Most social workers will tell you that, in reality, many bend the eligibility rules in favour of their clients all the time; this system would reduce the need to do so.
I’ll end with two possible ways of increasing the likelihood that the approach I’ve just outlined could achieve better outcomes, leading to people needing less expensive support.
First, we need to shift resources and expertise away from the processes designed to calculate a personal budget and towards support to plan. In a typical area, the process starts with an assessment of need, then a panel is involved in generating an indicative amount, then there is a planning process, then another panel approves or rejects the final amount. Then there is an appeals process. Instead, let’s start with a questionnaire about your needs and direction of travel (with the option to self-assess) which will suggest where you are within broad bands of eligibility, which give you a broad range of figures for your twelve month budget. Then an independent social worker is on hand to help you create a spending plan for the year. That person can advise on your eligibility and has a duty to verify that your self-assessment of need is accurate, but it is not their job to sign-off your budget. They help you draft a proposed budget which goes to an in-house team whose job is either to sign it off, or to suggest changes. If you can’t agree, that team can impose a lower overall budget, but it will have to show how that lower amount will meet all of your predicted needs over the next twelve months, making it hard to justify self-defeating short termism.
The current system is far too quick to reduce support (sometimes sending people crashing back into an expensive crisis) and far too slow to increase support to head off a crisis. Giving people the ability to spend money on preventative services could result in targeted, needs-led investment in the kinds of services which have often been shown to be effective, but which councils currently find hard to fund at the expense of reactive crisis services. You could reward people with greater freedom to spend with less need for reassessment, if they were able to make savings on their predicted budget. Individuals could have the right to bank a portion of any savings they made as an emergency fund, or as a capital investment in a home adaptation or to start up a new micro-enterprise.
I’m looking forward (kind of) to hearing all the new problems and perverse incentives you will, I’m sure, be able to spot in these ideas! We have a new social care statute on the way. If all it achieves is a more streamlined, clearer version of the current/ emerging system, that will be no bad thing. But let’s not confine our ambitions to that. What would your new blueprint for social care be?