Adult social care eligibility criteria - innovations and developments: report

Background

In Scotland, following the independent review of adult social care (IRASC) in 2021, social care is going through a period of further review. Final decisions are still being made about a National Care Service (NCS). One aspect under review is eligibility criteria. Specifically, the Scottish Government is committed to the "overhaul of the current mechanism of eligibility criteria to ensure an approach to adult social care support that is based on human rights and needs" (SG 2022b, p5). As part of a wider programme of work in advance of the NCS, this commission was undertaken with the understanding that the purpose was not to create an alternative mechanism, but to explore relevant developments and innovations in the field of adult social care eligibility criteria in the UK. This report is the result of that inquiry.

Wider context of social care in the UK

In some respects, the origins of the current crisis in social care in the UK are deep rooted and longstanding. It is important that any considerations of routes out of the crisis are set in context and influenced by understandings of the history of the sector, referred to briefly below. It is also the case however, that society in general is facing a unique and unprecedented conflation of social, economic and environmental challenges. This includes the cost-of-living crisis and the fallout of the pandemic, following a decade of austerity which saw harsh welfare reform and service cuts, impacting hardest on people on already low incomes (Galloway 2020). There is also a staffing crisis, influenced not least by low pay in social care. Finding solutions requires fresh thinking and greater adaptability and willingness to revise previous (well-intended) policy decisions more than ever before.

To outline some of the key policy background, some trace the conceptual roots of this system to the Elizabethan Poor Law distinction between the 'deserving' and the 'undeserving' poor (CSCI 2008). Unlike the NHS which started in the same year – the 1948 National Assistance Act did not herald the arrival of universal social care services accessible by all and free at the point of delivery. Instead, because the legislation clarified that councils were only obliged to provide care to people in circumstances where it was not otherwise available, publicly funded social care was seen as a 'safety net' rather than a universal entitlement (CSCI 2008).

The full history of social care in the UK is beyond the scope of this report, and has recently been explored in depth by Beresford and Slasberg (2023). Their exploration includes the different roles played by the disabled people's movement from the 1970s with a focus on the social model of disability and a right to independent living. While at surface level, there were consistent messages from the government of the time on a retreat from paternalism, cost containment was a strong motive which influenced how and to what extent more laudable policy goals could be attained.

Local authorities are responsible both for assessing social care needs and for providing support to meet those needs within a fixed budget. As noted in Appendix B, if someone is assessed as having eligible needs, legally the fact that there is insufficient budget does not constitute a reason not to meet that need. Tightening of eligibility criteria is the standard response in face of budgetary limits. It is important to understand the funding sources available to local authorities to spend on social care. Whilst residential care had long been subject to means testing, the 1983 Health and Social Services and Social Security Adjudications Act enabled councils to levy charges for home care and other services. This has meant that the resources available to councils for adult social care comprise government grants, a proportion of council tax receipts and income from fees and charges.

Following the NHS and Community Care Act 1990, which transferred funding from the benefits system to councils, councils were further obliged to manage a cash limited system. The 1990 Act also brought in the purchaser provider split, resulting in UK social care services being among the most privatised and fragmented in the Western world, whilst also underfunded for decades (Pollock et al 2021). Eligibility criteria, first introduced in England in 2008, were deemed necessary to balance budgets, through controlling spending. Charging and the criteria both act as rationing mechanisms (CSCI 2008).

A key theme which will be explored in this report is the interaction between policy, legislation and economic concerns on the one hand, and culture and practice on the other. The 1990 Act has also had profound impact on culture and practice in the UK, requiring an assessment of needs before public support could be offered to individuals, along with a means testing component. The concept of care management was introduced, with a focus on designing flexible packages of care, which were to draw from the independent sector (Means et al, 2008). Although the stated intention was a more person-centred system, social work became more administrative (Means et al, 2008). Care managers have since struggled to navigate the conflicting roles as public advocates whilst also acting as gatekeepers of a resource restricted system (Rummery 2002).

Eligibility criteria

The intention of eligibility criteria was that they would make decision making about allocation of social care resources equitable, consistent and transparent. The criteria identify four bandings relating to the level of risk involved (critical, substantial, moderate and low) as well as the urgency of need. A range of challenges has been identified including questions about whether the criteria deliver on the original objectives, with concerns raised even at an early stage of implementation about the increasing numbers being excluded from much needed support (Henwood and Hudson 2008).

While these authors acknowledge that local authorities have been obliged to find ways to ration resources in face of inadequate funding, the means of achieving this too often result in lack of prevention and deteriorating quality of life. There was also significant evidence that consistency was not being achieved in how the criteria were being applied within or between councils (Henwood and Hudson 2008). With regard to equity, they found inherent weaknesses, with young people in transitional groups and older people most disadvantaged. While this research did not include self-funders, it is important to note that self-funders were often the most disadvantaged and isolated in the system (Henwood and Hudson 2008).

The Commission for Social Care Inspection (CSCI) then published its research report Cutting the Cake Fairly (2008). This identified that the size of the social care funding 'cake' was too limited, while the numbers in need of a slice was increasing, concluding: In the long term, there is no alternative to radical reform of the way the social care system is funded(CSCI 2008 p1).In the absence of a larger cake appearing, eligibility criteria remain a crude tool for managing annual local authority spend. If someone is assessed as having eligible needs – legally - the fact that there is insufficient budget isn't a reason not to meet that need (through statutory service provision). The way round this is to tighten eligibility criteria.

Eligibility criteria were introduced slightly later in Scotland than in England, in 2009, as agreed by the Scottish Government and Convention of Scottish Local Authorities (COSLA). Although initially developed for older people, they were purposefully designed to be applicable across all adult care groups with the intention of aiding (individual and collective) decision making in the face of limited resources and increasing demand. Currently, Wales and England have nationally determined eligibility criteria for carers' support, whereas in Scotland and Northern Ireland this is decided locally (Needham and Hall 2022).

The recent IRASC in Scotland found widespread views that the threshold for accessing support was too high, leaving people seeking support and carers struggling with deteriorating mental and physical wellbeing. The assessment process was described as intrusive and overly focused on deficits. Social work staff identified that they were unable to work with people in person centred and enabling ways due to the focus on gatekeeping: "As one social worker put it to us: It's the equivalent of NHS staff having to make a case for funding every time someone needs a blood test" (SG 2021, p28).

Before discussing the project, it is worth mentioning the context of social work and social care in Scotland has been further complicated in the intervening years by a raft of additional legislation. While founded on well-intentioned principles, this often requires transactional elements which don't necessarily correspond with the principles (Miller and Barrie 2022). A key example relevant here is the Social Care (Self-Directed Support) (Scotland) Act 2013. Its emphasis on choice and control of funding options is linked to a requirement to calculate the level of resources (budget) available, usually occurs at an early stage, requiring new standardised mechanisms, as discussed with reference to relevant literature below.