Where do we find abundance in a time of scarcity, asks ResPublica Associate Alex Fox
Social care reform often seems to be at the back of a very
long queue. Whilst the voting public is readily passionate on the subject of
the NHS, the long term care and support of older and disabled people is a
murkier world. Surveys consistently show that people don’t know what social
care is, although most of us have some experience of a family member using a
care home, home-based care or a community care service. The public also remains
of the belief that social care is part of the NHS, whereas it is of course run
entirely separately by your council, and that, like the NHS, it is free for
everyone.
When Bevan was inventing the NHS, what we would call social
care was carried out by families, largely by women, or in the case of disabled
people and those with long-term mental health problems, often out of sight in
large institutions. As people’s expectations and the nature of families
changed, state provided social care grew, but remained - and is increasingly –
reserved for those with the greatest needs and only free for those with little
income or assets. Anyone can turn up to demand the free services of a highly
paid GP, whether you have cancer or the common cold. But the 90 year old who
needs help arising from dementia may fight a months-long battle through a
tortuous assessment system for entitlements to twice daily rushed visits from a
succession of unqualified strangers.
Part of the problem is how social care is funded. The most
visible debates have centred on the one aspect of reform which no one is surprised
the government hasn’t settled in the White Paper, nor in the draft Bill. The
Dilnot commission suggested that the means-test for free social care be raised
from £23,250 to £100,000 (which includes the value of your house) and that no
one should pay more than around £35,000 in their lifetime for social care.
Currently, social care costs can wipe out estates worth well over £1 million. The
cross-party talks on Dilnot’s solution, which would cost at least £1.7billion a
year, have not resulted in a funding commitment (despite, by coincidence, the
Treasury pocketing exactly that amount in NHS savings), raising the prospect
that Cameron will be no closer to keeping his promise to middle class voters
that they won’t lose their houses to social care costs than Blair or Brown.
But the problem is not just about how social care is funded,
nor even the undoubted shortfall in the amount we are willing to put into
funding it from taxes. There is also an unfinished revolution taking place
which is changing the nature of social care. It is in this area which the White
Paper is most radical. Whereas the NHS vision is one in which we become
informed consumers, choosing what we like best (or perhaps dislike least) from
what is on offer from professionals, social care has been reshaped for a number
of years around the idea that we are the experts in what kind of life we want
to live and should have as much control as possible over not only the choice of
services, but the shape of those services, including in some cases having the
option to design and own new services ourselves.
For instance, the older person who doesn’t want to spend
their personal budget allocation of council money, or more likely their own
hard-earned money, on the aforementioned clock-in, clock-out home care offered
by a large agency, can in some areas find a worker who has decided they don’t
want to provide off-the-shelf care either, and has set up their own small
‘micro-enterprise’, designed to meet the needs of a small group of older
people. In one instance, the proprietor, who has years of hands-on care
experience, delivers the first two weeks of care herself, before matching new
clients to one of her tiny team, ensuring consistency and giving the older
person the opportunity to specify what they want the worker to help them with,
which may include meeting up with friends, rather than simply being helped to
dress and eat in preparation for another day spent alone at home.
These kinds of ‘micro’ solutions, made possible by giving
people control over their individual budget allocation and then connecting them
with each other, are still the exception, but they demonstrate what is possible
when public services are able and willing to get to their ‘customers’ as
individuals and to offer a relationship, not just a service. Other examples
include Shared Lives (highlighted in the White Paper), in which registered
Shared Lives carers share their own homes and family life with an older person
who visits them instead of visiting a day centre, or with an adult with a
learning disability who may move in with them on a long term basis, putting
down roots in a community, rather than existing in the kind of out of town
institution which was seen to be failing so shockingly in the BBC Panorama
expose of the Winterbourne View facility. There are already 15,000 people using
one of 150 local Shared Lives schemes and the sector is expanding whilst more
expensive institutional care struggles to survive.
There can be few public services not reducing their budgets
at the moment and social care services are no exception. But the shift from
care provided which leaves people isolated at home or in expensive
institutions, towards family and community-sized interventions designed to keep
people engage in relationships, not just service transactions, is not only a
better solution, it is an austerity solution, often costing less as people have
the freedom to offer more care than can be specified in a contract and allowing
recipients of care to find ways to connect with and contribute to those around
them. It is being seen in some quarters as pointing the way for other public
service sectors, where the mantras of individual choice and payment by results
have not delivered hoped-for revolutions.