03 February 2006
This week's health and social care white paper promises joint working and preventive care in the community. But NHS deficits and social service cutbacks mean the trends are pointing the other way. Tash Shifrin reports
Two notions have long dominated public perceptions of social workers. The first is that they are interfering busybodies 'who want to take your kids away'. The second is that they are negligent bumblers who fail to remove vulnerable children from abusive carers. The twin myths not only conceal the more subtle and challenging realities that social services departments face but also hide a starker truth – most recipients of social care are not children but adults.
In England in 2003 around 388,200 children in need were known to social services. Some 61,000 of these were looked after by the local authority, far short of the 450,000 adults under 65 using social services, never mind the 1.2 million older people receiving social care.
But public interest in the state of adult social care is mounting. Long the poor relation to the NHS, the service is now being pared back even further, despite the rising proportion of elderly people and concerns about future pensions provision. Services that not so long ago were seen as the mainstays of support, such as hot meals and help with cleaning, are being provided to fewer and fewer people.
NHS reforms – an expanded role for GP surgeries, a new future for cottage hospitals and the onward march of the private sector into primary care – stole the headlines as this week's community services white paper was published. But the document also carries forward into adult social care the government's public service reform agenda of increasingly individualised services, greater choice and an emphasis on preventive services.
It pushes for far greater integration of health and social care, with increasingly aligned performance indicators and budget cycles, and more joint teams and services. The white paper proposes an extension of direct payments and restates the government's commitment to individualised budgets bringing social care and other income streams together so people can choose and purchase their own care. There is also a beefed-up role for directors of adult social services, under new statutory guidance, while services to carers will get a boost.
There is to be a review of the social care workforce, along with a new board-level director of social care post at the Department of Health – a move NHS chief executive Sir Nigel Crisp says will help 'strengthen the position' of social care in the department.
Also in the pipeline is the review of social care for older people by former NatWest chief executive Sir Derek Wanless, who led two government-commissioned reviews into future health and health care spending. The new review, commissioned by the King's Fund think-tank, will report in March on models of care and funding, looking ahead to the next 20 years.
But stepping into a rosy future might not be so easy: social services are struggling with the dilemmas of the present. And the pragmatic measures adopted to deal with an increasing mismatch between demand for services and funding are themselves shaping the future.
Local authorities and social services chiefs warned in January that the local government funding settlement for the next two years would lead to cuts, tightening of eligibility criteria and increasing user charges for social care. Authorities from the Eastern region have written to the government in protest, while county councils in the South and Southeast have also warned of cuts.
Everywhere, as councils move to set their budgets, social services are under pressure. Rochdale is considering £1m cuts to adult services, while Norfolk, where every year another 800 older people need support from the council, is consulting on options that could mean the loss of 304 care home places or 456 intensive home care packages.
Perhaps worst hit is Suffolk, where adult care and community services could be cut by £14.5m (see below).
Sir Sandy Bruce-Lockhart, chair of the Local Government Association, says that as the proportion of elderly people increases and people with more complex needs survive longer, cost pressures are running 'way above' the settlement figures of 2% for 2006/07 and 2.7% the following year.
'The number of care weeks for people over 85 rose by 5.5% over the past year, while the increase for disabled adults and those with learning difficulties was 9%,' he says. Add in the rising bills from private providers and 'there's a real issue'.
Anne Williams, co-chair of the Association of Directors of Social Services' resourcing committee, adds that many social services departments are already overspent, particularly in learning disability services.
But rationing has been a quiet reality for years. Help the Aged policy officer Jonathan Ellis says service users have felt the pinch. 'There's a great deal of worry that people aren't able to access the sort of services they need at the time they need them.'
Williams admits that social services departments' response to straitened finances – raising the threshold for eligibility for services – is 'a worry'. Traditional day care for people with simple needs – hot meals and company – is going by the board, despite their importance in reducing elderly people's isolation and allowing staff to keep an eye out for them.
'Other services, like cleaning, matter a lot to older people but most local authorities can't provide it any more. People have to pay themselves,' she says.
The trend for targeting resources at those at the highest levels of need – dubbed 'critical' and 'substantial' – was highlighted by the Commission for Social Care Inspection in a mammoth report, The state of social care in England 2004/05, published at the end of last year. There was evidence of councils 'disinvesting' in simple support, while the number of households receiving intensive services rose by 14%. 'Fewer people are receiving the care they need to enable them to live independent lives in their own homes,' the report says.
The policy is 'short-sighted', CSCI argues. Chief executive David Behan says: 'They're making services available to fit the resources rather than to fit the needs of people in the community. Effectively, they're saying no to people.'
This reality of targeting, which has grown organically from councils' lack of resources, cuts right across the white paper's emphasis on more preventive, low-level care, says Help the Aged's Ellis. 'The government talks the talk of shifting to the preventive model but, in reality, we've seen low-level social care, which can be so important, cut by not far off a third since 1997.'
The other main way of stretching social services resources is to pass some of the cost on to the users themselves by increasing charges. Williams says departments up and down the country are looking at this.
But, as well as hitting elderly people who are above income support levels but have little cash, the move often heightens inequity. In three London boroughs, charges for the same care package have been found to vary by £30 a week.
Williams says: 'We welcome the white paper's emphasis on more care in people's homes and in the community and less dependence on A&E and hospitals. But the issue is whether there is going to be a move of investment in health services from the acute sector to more community and primary care and is there going to be investment in more social care in the community to support people?'
The white paper leaves funding questions open until the report of Sir Michael Lyons' inquiry into local government, although it does mention 'specific resources' to meet 'additional costs for some elements' of its proposals.
The problem for social care funding is not only the squeeze from the tight local government settlement. Joint working between the NHS and social services – a central white paper theme – has brought its own
financial headache, where primary care trusts struggling with the NHS's financial deficits have sought to shunt costs on to their partner local authorities.
Ray Jones, director of adult and community services at Wiltshire County Council, has warned that his local PCT is operating a 'narrowing definition' of its responsibilities, pushing care costs on to his authority.
His warning is echoed by the LGA's Bruce-Lockhart, who says: 'We're hearing these reports from across the country.' Even Health Secretary Patricia Hewitt has acknowledged that the phenomenon is 'a real problem'.
Williams warns of a different knock-on from the NHS's financial problems. 'There are some PCTs saying they won't be able to pass over money previously agreed on in partnership arrangements – and that's beginning to have an effect.'
Williams adds: 'That's a real problem for the sustained joint working that the white paper demands.'
More joint commissioning and pooled budgets are welcome, but ADSS president Julie Jones warns: 'Any resources transferred must be transparently transferred, and stay transferred.' The 'turbulence' in PCTs puts implementing the white paper at risk, she says. The ADSS wants a statutory duty on the NHS and local government to co-operate on joint objectives to be written into forthcoming legislation.
Could lack of resources hamper another major plank of government public service reform? The white paper also firms up government plans to give service users individual budgets to choose and purchase their own care.
The scheme – welcomed in principle by service users and professionals – is already being piloted. Social care minister Liam Byrne has pledged to take full note of the evaluation findings – and all eyes will be on the costs of the scheme. There are serious doubts that it can be managed within existing budgets.
The CSCI report warns: 'Increasing people's choices is not cost neutral, requiring the sum total of available services to exceed needs at any one time. Such unfilled capacity brings with it additional costs.'
Williams says bluntly: 'We don't believe it can be cost neutral.' She points out the tensions that exist between the idea of individual budgets to promote users' choice and suggestions from the Department of Health that more block contracting be used to help make Gershon efficiency savings. 'Block contracting conflicts with individualised services because you want to fill beds,' she says.
More cheerfully, Bruce-Lockhart argues that while there is additional expense in providing a range of services for people to choose from, there can be 'significant savings in transactional costs' for councils.
His own authority, Kent, has given smart cards to 100,000 social care recipients, which allows them to select their own care electronically. The system has wiped out the processing of endless paper invoices by the council. 'Now it's all done by the Royal Bank of Scotland, by smart card,' he says.
But there are also question marks over whether individual budgets will help people with lower level service needs. Will they even receive direct payments or individual budgets to purchase care? 'As things are going, no,' Williams says. 'Two thirds of authorities are only dealing with people with critical and substantial needs.'
Behan urges social services to work more efficiently and more effectively to increase the reach of social care. But he adds: 'If we're going to get a step change, we need to think about where additional resources are going to be made available.' In particular, he stresses the need for resources to be pumped into the low-paid, underqualified workforce that is taking on increasingly complex jobs.
Byrne has admitted it could take 'one or two Comprehensive Spending Reviews' to reach a level of funding that all those involved are 'more comfortable with'. Whether more resources will be forthcoming – and when – is another matter.
Other changes make the future even less certain. The impact of major organisational upheaval in social services as a result of the 2004 Children's Act – which will bring children's social services together with education in new children's departments – has yet to be fully felt. Adult services face more financial worries as budgets are disaggregated – a process that could affect different areas very differently as the proportions of social services cash spent on children and adults vary hugely.
Some longer-term thinking is going on, however. Wanless review project manager Julien Forder says the March report will consider three scenarios for the shape of social care in 20 years' time, including one centred on the concept of 'wellbeing' – not currently a focus of the British social care system.
Among other questions, Forder hopes it will address 'to a certain extent' whether social care should remain with local authorities and where the line between health and social care might fall.
Finance will be 'very much at the heart' of the report, with options under consideration including means testing, an 'entitlement' model and private and public forms of insurance. Everything is up for grabs.
The report will also consider a question that few involved in social care finance at the moment would dare to raise – the scale of unmet need. 'There's clearly a set of people who could benefit from services but who aren't receiving them at the moment,' Forder says.
While there are figures for those receiving social services, no-one knows how many people currently miss out. 'We'll certainly try to come up with an estimate... to quantify what that level of need would be and put some numbers on it. I think it's a first attempt to do that in a systematic way. That will be the centrepiece.'
The Wanless team has the luxury of being able to decide the aims of a future system and then the means. It will take quite a shift from a service increasingly shaped by the means available.
Suffolk suffering
The local government settlement has been a big blow to Suffolk County Council. It is set to cut £14.5m – 10% – from its adult care and community services budget, which includes libraries and adult learning as well as social care, as part of £24m cuts overall. Council papers cite £4m from 'PCTs' withdrawal of discretionary funding for long-term partnership schemes' as another cost pressure.
The papers suggest that changes to day care services for elderly people will mean that 'unless less costly alternatives are found, many older people will be without day services', while services for people with learning difficulties face a shake-up, with a mix of service closure and reprovision. This will mean more targeting: some users will no longer be eligible for services, others face the introduction of charges.
Funding for preventive services will be cut by £100,000. The number of care packages provided will also be reduced. Charges are set to be increased for meals on wheels, while more money will also be raised from home care charges.
'It's pretty horrible,' says councillor Jane Midwood, the adult care and community services Cabinet member. 'We're already seeing effects. We've got a very worried population, particularly of elderly people. We can't do anything else, though — we've got to find £14m. I'm devastated.'
Some savings will be made through efficiency, but she says: 'There will be [a loss of services] to some people, yes. By and large, services to people with learning difficulties are going to take the biggest cuts, but I'm sure people caring for older people will say they're the most hard done-by. It's a no-win situation.'
Suffolk's social services have been awarded top ranking of three stars by inspectors, but Midwood says: 'That's going to be very hard to hold on to under financial constraint.'
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