Adult social care eligibility criteria - innovations and developments: report

Appendix E

Everyone is eligible to be understood

Mark Smith – Director of Public Service Reform, Gateshead Council, England

Mark stated his mission is to create "an ecosystem of public services responding in more relational and intentional ways to the real causes of people's needs." Mark described aspects of work intended to help people in Gateshead to thrive in the medium to longer term as well as attending to what they need right now. Gateshead is a deprived borough and the work began with the aim of getting beneath inequality and poverty by learning more about holistic practice. They conducted a series of experiments and collected data to support learning and improvement. The work generated learning about eligibility criteria as a by-product of experimenting with new approaches to holistic practice.

Approach:

One early experiment involved work with 40 families who had amassed significant council tax debts. Despite repeated interventions, they were now facing eviction. On working to find out what was going on, they found that 96% couldn't pay. However the system was designed based on punitive assumptions about the 4% that wouldn't pay. They then set up a team of caseworkers and specialists including a DWP work coach and Citizens Advice advisor. Over six months the team had carte blanche to do whatever would support people to thrive with the exception of 2 rules: don't break the law and don't do any harm. The guiding principle was to replace assessment with understanding: understanding what matters to you and what does a good life look like. In the end, 70% of the families were living a better life as a consequence - and the learning was considerable.

Requirements:

• o Seek to understand rather than assess
• o Embrace complexity
• o Prioritise the relationship with the citizen and the caseworker (or person best placed to be involved*)
• o Move at the pace of the citizen
• o Seek to rebalance rather than refer - pull in specialist expertise where appropriate rather than perpetuate the cycle of assessment, referral, assessment
• o Attend to the supply side by building relationships and networks with as many different people as possible who want to contribute

What They Learned about the Consequences of Eligibility

Eligibility creates demand (over time)

Looking across housing, social care, policing, criminal justice and health, they found that 75% of people with highest needs had previously been screened out because they were "not bad enough". Eligibility is a form of demand management – not demand reduction. It is a mechanism induced by scarcity and when demand fails to decrease there is a temptation to keep raising the bar. However, this serves to increase demand in terms of pure numbers and the acuity of the demand. The data collected showed this was provable when you looked at different systems and accumulatively when you added it together across systems.

Applying eligibility criteria doesn't come for free

Lots of process and capacity are used up in setting (and re-setting) criteria, applying them, determining whether they are met or not and arguing about the criteria within and between teams and organisations.

When looking across case histories, they found that checking outweighed doing 2:1. The significant demands placed on the system could be redirected to improving outcomes. The waste doesn't stop there, but is reinforced e.g. by the inspectorate.

Eligibility also disassociates and decouples the relationship between the citizen, the person working with and the people who make decisions

Assessments don't work for people (or organisations) because they are for us

Assessment is predicated on "how much of what we do can we do to you"? "How much of what we have can we give to you"? It uses standardised approaches with non-standardised people. The result is you get screened out or screened in. And if you get screened in this typically results in referral followed by another assessment. The context is often missed and multiple assessments with no action was common. People don't feel understood.

Looking at a particular group of 8 people over a 2 year period, they found that they had been assessed 350 times between them - and life was no better.

What They Learned When They Turned Eligibility Off

Bespoke by default works

The importance of moving at the pace of the citizen, building trust, teasing out nuances, attending to what matters now and understanding their idiosyncrasies, so you can go on to understanding what matters ultimately. The relationship between the citizen and the case worker was sacrosanct and referral was replaced by pull – if expertise was needed it was pulled in: can you help us with this problem?

Mark also spoke about the 'system fighting back' when eligibility are turned off, with resistance coming from different points in the system. There was therefore a need to work across different points of leverage (POL).