National Care Service unlikely to end postcode lottery
by Jennifer Roberts
This article appears in the Journal of Care Services Management, of which Jennifer is joint editor.
Can the Government’s new blueprint for a National Care Service end one of the great injustices in England today: the postcode lottery of social care? The ‘vision for the future’ outlined in Shaping the Future of Care Together, includes a proposal that is specifically designed to achieve this – a national assessment. But the route to this particular goal promises to be long and arduous. This paper argues that the funding options detailed in the lengthy green paper raise serious questions over whether a ‘fair for all’ care and support system can become a reality.
INTRODUCTION
Cutting the Cake Fairly, a report produced in October 1998 by the Commission for Social Care Inspection (CSCI), identified that a growing number of people had found themselves excluded from the social care system. The CSCI found that, in some areas, councils had not taken a needs-led approach, but had used eligibility criteria bandings to categorise services on the flawed assumption that so-called ‘low-level’ services were only required by people identified as having low eligibility. This had meant that some invaluable services had been cut.
The CSCI said they recognised the size of the social care ‘cake’ was limited, while the number of people who wanted a ‘slice’ was increasing. ‘In the long term there is no alternative to radical reform on the way the social care system is funded. However, we are unable to avoid the conclusion that the key issue is not simply the criteria used to assess people’s eligibility for publicly funded care and support, but the amount of resources currently allocated – the size of the cake itself.’
The report said that, for many people, the postcode lottery was no longer acceptable if it resulted in those with similar needs for support being treated wholly differently in different parts of the country. It identified several different postcode lotteries in social care. For instance:
· The differing application of FACS (Fair Access to Care Services), resulting in differential access to support and the lack of ‘portability’ of assessments;
· A big range in the charges levied for non-residential services;
· Wide variations in the support offered to carers; and
· In the provision of open access services.
CSCI said in their annual State of Social Care Report in January 2008 that 73% of local authorities planned to refuse care to people whose needs were not considered to be ‘substantial’ or ‘critical’.This excluded people with ‘moderate’ needs who could not carry out daily routines such as getting up in the morning, bathing and doing the washing up.
The green paper recognises that the current system has significant weaknesses. It accepts there are wide variations in the standards and quantity of care and support offered by different local authorities. ‘Such postcode lotteries are worsening as funding struggles to keep pace with rising numbers of older people in need of support. There are few clear rights or entitlements underpinning the service, and what people can expect to receive is often unclear until they actually apply for support’, says the document.
In simple terms, the current system has meant that many vulnerable people who need social care do not receive it. People with similar needs have been getting different responses, depending on where they live. Former Social Care Minister Ivan Lewis told The Guardian newspaper in January 2008 that the rationing of services for frail and infirm people in England had become inconsistent and unfair. He said increasing numbers of local authorities were imposing a vulnerability test to deny help to people whose condition was not yet serious enough to be life-threatening. ‘There is no logic to explain why some people are given support and others are not,’ he said.
WHAT THE GREEN PAPER SAYS
The Government illustrate how existing local authority boundaries create geographical barriers for people receiving care and support. Eligibility for care and support differs between authorities and care is not easily ‘portable’, they say. When a person wants to move, they can’t take their needs assessment with them and they must have a new assessment in their new area. ‘Under the current system, people cannot find out in advance what care and support they are entitled to if they move to a new area. So we want to introduce a new assessment process that tackles these issues.’
The ‘vision for the future’ includes a list of six things that the Government says everyone in the country should be able to expect: prevention services, national assessment, a ‘joined-up’ service, information and advice, personalised care and support and fair funding. Explaining their ethos for national assessment, they say: ‘Wherever you are in England, you will have the right to have your care and support needs assessed in the same way. And you will have a right to have the same proportion of your care and support costs paid for wherever you live. You will be able to take your needs assessment with you wherever you go, so wherever you are in England the assessment of your needs will be the same, enabling you to live the life you want wherever you want.’
The Government go on to say: ‘People have told us that they want a system where they are not at risk of losing their care and support just because they have moved somewhere new. At the same time, flexibility in the funding and delivery of services at the local level will need to be key so that local authorities are able to respond to local needs and local priorities.’
Under the plan for re-assessment, people would not need to be re-assessed unless their needs changed. When a person moved, their assessed level of need would only change if their circumstances were different (ie if friends and family could not offer the levels of support they had previously provided). ‘With a nationally portable assessment, people will be able to contact the local authority of the area they want to move to and discuss what care and support will be available to them.’
However, the Government add that a national assessment would not guarantee that people with the same assessment in different parts of the country would be able to choose exactly the same services. ‘We believe that local authorities should have the space to innovate and the freedom to shape services according to the needs of their local area. But it does mean that people should know what their needs have been assessed as, and that the local authority will help them to ensure that those needs are met. Local authorities will be able to tell them what is available for them before they move’.
ACHIEVING NATIONAL CONSISTENCY
At the heart of the Government’s drive for a National Care Service is their belief that the care and support system should be fair and universal. In other words – that everyone who qualifies for care and support can get it, regardless of where they live. It is striving for a flexible system with local services designed to respond to what people need in a particular area – and to encourage innovative approaches. Under a standardised needs assessment process, the Government would set the level of need at which someone qualified for state funding – and would set, nationally, what proportion of someone’s care package would be funded by the state.
In Shaping the Future of Care Together, the Government make clear that local authorities will be ‘key to the delivery’ of the National Care Service and underline in no uncertain terms the ‘continued and strengthened role’ they will play in the reformed system. ‘Local authorities must be able to innovate at the local level to ensure that the right services are available in their local area, that services are being properly delivered and that people are able to access them. This role will be essential in ensuring that people who need care and support are able to get services shaped to their needs. The critical role of local authorities cannot be underestimated and, as such, this green paper is aimed as much at them as it is at individuals.’
The Government outline two options for making the reformed system work, both of which have different implications for the way in which money is raised and distributed throughout England:
· A part-national, part-local system;
· A fully national system.
It has been made clear that under either system, local authorities would play the key role in delivering care and support.
PART-NATIONAL, PART-LOCAL SYSTEM
Under this system, people would know that they were entitled to have their needs met, and a proportion of their care and support package would be paid for by the state, wherever they lived. But local authorities would be responsible for deciding how much an individual should receive to spend overall on care and support, giving them the flexibility to take into account local circumstances.
The Government say the advantage of this system would be that local authorities would be able to set the actual amount of funding that someone would receive. ‘This could provide more space and flexibility for local authorities to encourage new kinds of care and support in their area. It would also help them respond to local conditions to deliver real choice and control for individuals. But it would mean that people could still get different amounts of funding in different places, which might be seen as unfair’.
The Local Government Association are strongly supporting this option, calling for a single, transferable assessment of needs and means being applicable anywhere in the country, with the services to meet need and the amount to pay for them decided locally.
FULLY NATIONAL SYSTEM
Under this system, the government would decide how much funding people should get, instead of local authorities. The amount of funding allocated could be consistent across the country, or could vary depending on location to take account of the different costs of care across England.
The Government say the advantage of this system is that it would be easy for people to understand and plan for. It would enable people to move around more freely and live the lives they wanted, wherever they were. The disadvantage of the system, adds the Government, would be that it would decide at national level how much funding someone was going to receive. ‘It could be more difficult for local authorities to tailor the care package that people receive to their wishes and to respond to local circumstances, and it would make the system more rigid.’
There is a warning that a fully national system would almost certainly pave the way for major changes in the way in which money for care and support is raised and spent in England. Local authorities presently can decide to fund social care by using funding from council tax over and above the funding they receive from national government. The Government say if they, rather than local authorities, were deciding how much funding people should get, it would be unfair to ask local authorities to fund this new system from money they raised themselves, as they ‘would have no way of controlling these costs’.Under a national system, all funding for care would probably need to be raised nationally through national taxation instead of a proportion of it coming through council tax.
Not surprisingly, the LGA are strongly opposing this option. Pointing out that local government contributes about £5.3 billion to the total adult care spent of more than £13 billion, with councils funding more than 80% of adult care expenditure through council tax, they warn that a national system would:
· Undermine councils’ flexibility in commissioning and designing care services around the needs of the user;
· Hamper the ability of councils to join-up social care, health, housing and other systems to provide better outcomes for local people;
· Be less responsive than a locally-funded and locally-managed system;
· Lessen accountability by removing overall decision-making from democratically elected local councillors;
· Change the nature of local government funding, which could reduce local flexibility.
THE ROLE OF LOCAL AUTHORITIES
The green paper says local authorities will be vital in helping to achieve the balance between promoting innovation, enabling people to have choice about services and ensuring that the right services are available for people whose situations make them vulnerable. As more people held personal budgets and chose different forms of care and support, local authorities would have a key role in ensuring that the market in their area was providing the kinds of services that people wanted. They would need to find ‘new ways’ in which to influence which services were available in their area. They would have a role to play in helping the private and voluntary sector to adjust to a different way of responding to people’s wishes and needs.
Local authorities would be expected to support care providers. As more people begin to design their own care packages, local government may need to help providers to think of individuals as being their key customer – rather than the local authority. ‘Many people who have personal budgets will still ask local authorities to commission services for them, but this will require more flexibility from authorities. Local authorities will need to think about how they can get the best value for money from commissioning, and whether they should reserve any funding for market development, while retaining local flexibility. Local authorities could work with care and support organisations from the third and private sectors to help them understand the likely patterns of need in their area. They could involve private and third sector providers and representatives in their strategic needs assessment as part of their broad commissioning role and develop risk sharing between the private and public sectors.’
CONCLUSION
The distinct lack of detail on how the two options (part national-part local/fully national) would be financed makes it very difficult to establish the best way forward. Both options are flawed. One clear disadvantage under the part national-part local system would be that people would almost certainly get different amounts of funding in different places. The main drawbacks of a fully national funding option are clearly identified in the green paper. Namely:
· It may be more difficult for local authorities to tailor care and support packages to people needs;
· People who live in areas where care and support is very expensive might not be able to afford as much care and support;
· Because this system would not be as flexible to people’s needs and would be less able to respond to local variations, it might not therefore offer such good value for taxpayers’ money.
· This loss of flexibility would be a particular risk when planning how local care and support services work with services provided by the NHS.
You don’t need to read between the lines to see that the Government favour the part local-part national option. Perhaps it is the most sensible way forward. But, with there being no plans to tackle the way local authorities prioritise their services – and funding for care services continuing to vary across the country – they have clearly failed to allay fears that the postcode lottery will come to an end.
Gordon Brown, in his Labour Conference speech, said that reform of social care would be a priority before and after the General Election. But this presents another problem. With 2010 being election year – and with the Government fighting a rearguard battle to stay in power – there is no guarantee that the proposals within Shaping the Future of Care Together will get past the drawing board.
April 5th, 2010 at 9:18 pm
cool article.
robe noire
April 16th, 2010 at 2:13 am
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