09 November 2007
The Comprehensive Spending Review held no surprises with only small increases in budgets. But how does this match with the rising needs of vulnerable older people, asks Anne Williams
Last month's Comprehensive Spending Review came as no surprise to directors of adult services and many in the voluntary and private sector. Never has an announcement been trailed over such a long period of time to so many stakeholders.
From last spring's Budget the message has been loud and clear: don't expect too much. Only those who either ignored the warning, or didn't hear it in the first place, should be surprised.
In the end, yes, it is disappointing that health accrued some 4% growth while local government secured only about 1%, although the comparative rates of resource decline can't be that different.
Saying that doesn't make us any less aware that adult social services are currently not reaching all the parts they ought to. We are fully aware, as was the Commission for Social Care Inspection last February, that although the quality of services has shown a steady increase, the quantity has diminished. And those increases in quality have been achieved despite having to make some of the toughest Gershon-inspired efficiency savings within the entire public sector.
Where we are able to act on behalf of vulnerable adults, we are effective. But there are more and more areas where we are unable to act, for capacity and resources reasons.
However, the government made two acknowledgements last month, which, if not offering hope for the future, at least suggest that pessimism isn't the only reasonable reaction to the CSR announcements.
First, ministers have begun to recognise the parity of importance between social and health care when it comes to providing and commissioning services for adults and older people. Launching the new inspection and regulatory body for adult care – the Care Quality Commission – Health Secretary Alan Johnston spoke of his determination 'to ensure that the distinct needs of social care are recognised by the new regulatory body, and that it uses and develops the expertise of the Mental Health Act Commission'. People responsible for establishing the CQC will need to consider the impact of the secretary of state's emphasis and act accordingly.
Secondly, the government has announced its intention of publishing a green paper on financing care for the elderly. We know and understand the government's concern, even wariness, about raising expectations that can't be delivered. Sir Derek Wanless, in his first, famous, report on NHS funding warned the government that spending on the NHS shouldn't get too far out of kilter with personal social services spending – a warning not sufficiently considered at the time. His second report, bravely commissioned by Niall Dickson at the King's Fund, spelt out the options with the clear, if by now well-rehearsed, view, that doing nothing was not a viable option.
That was more than a year ago. It wasn't until the CSR announcement last month that the government agreed to go ahead on an issue that has been around since the Royal Commission on Long-Term Care for the Elderly reported almost a decade ago. The majority on the commission, chaired by Sir (now Lord) Stewart Sutherland, argued for free social care for older people. Two of the commissioners disagreed. The report, however, opened up a limited debate in England with the government, backed by the former Association of Directors of Social Services, firmly setting itself against free personal care.
It was interpreted differently in Scotland, where free personal care was introduced a few years ago. Despite the differences in the scale and type of economies, it seems that the difficulties arising there are precisely those that the ADSS warned of in the late 1990s when Sutherland reported: severe demand pressures are threatening to lead to either prolonged cash crises or extensive rationing, with some important service-oriented issues arising in between. We wish the Scottish government luck in the review of personal care that it has recently set in motion.
Although the ADSS, now the Association of Directors of Adult Social Services, does not favour free care, it has not debated internally or publicly the balance needed between the respective duties and obligations of the individual, the family, the community and the state. We know, though, that without a doubt, if we are to be able to provide help and support for more than the most urgent of cases, additional money is needed.
Whether that be 'new' money, (and our own surveys with the Local Government Association have put the extra needed at somewhere more than £1bn) or money recycled from other budget heads is a matter for continuing political discussions. But directors of adult social services have repeatedly pointed out that we have to make certain that NHS and local authority resources are kept in a rational balance with each other if genuine whole-system policies are be put into effect.
Two major developments will continue to put question marks over the sums needed to bring the government's personalisation agenda into operation. The first is individual budgets. A number of authorities in England are piloting different methods of giving older and disabled people greater control over the budgets available to them.
It is too early to predict what impact such personalisation will have on commissioning patterns and on the care market itself.
The ADASS has stressed, however, that it is unlikely that cost-neutrality, one of the aims in the original white paper, will be easily maintained. It is fairly clear that pump-priming funds would be desirable if we are to pursue these new government policies while continuing to discharge our responsibilities to current service users.
Additional costs are also likely to be involved if an important complementary aim of the ADASS is to be realised: to strengthen the statutory framework within which adult social services departments and their partner agencies can act to protect vulnerable adults. A decision to pursue these legal changes was taken in the ADASS Executive Council only last month. Members took it, fully aware that asking vulnerable members of our communities to take greater responsibility for their own decisions exposes them to greater risk of abuse.
An important contribution we can make to ensuring that the balance of protection is kept level is to seek greater statutory duties for health, police and other agencies to collaborate with the ADASS in adult protection investigations, and to impose a duty on local authorities to investigate abuse allegations on behalf of adults roughly in the way children's departments are obliged to protect children.
The ADASS saw the CSR announcement not only as a challenge but as an opportunity to represent fully the interests of all our citizens – not only the more vulnerable – when the national debate augured by the green paper is joined.
Anne Williams is the president of the Association of Directors of Adult Social Services
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