Adult social care eligibility criteria - innovations and developments: report

Discussion/Conclusion

This work was commissioned with agreement that it would not attempt to produce an alternative tool to determine eligibility for social care. Freedom from this quest has enabled more open discussion about wider systems of social care.

Eligibility criteria have been a thorn in the side of social care in the UK for some time, starting in England around 20 years ago. The stated objectives behind eligibility criteria are equity, consistency and transparency. However, through categorising human needs as ineligible unless hitting a sufficient (substantial or critical) level, the existence of such mechanisms serves to mask chronic underfunding of a sector which has never enjoyed the same political or public status as the health service, or education. Some of the current discussions about structural reform of social care underplay the fact that there are limits to what can be achieved when there is not enough cake to go around. The urgent need to find adequate pay for social care staff in particular, and a need for a plan for progressively increasing investment over the coming years were both emphasised in this research.

Eligibility criteria are one mechanism creating tension in the social care system. They are far from being the only culprit however. Access to social care, for many, is currently fairly represented by the game of snakes and ladders which if anything underplays the range of ways in which people's needs remain unmet, with some not even attempting to gain access due to lack of awareness, fear of rejection and not knowing the right language to use. Separate work is being planned to explore unmet need in social care – how to define, identify, record and respond to it. This is an important corollary to eligibility criteria, and the findings will contribute to decisions about what happens next. Charging for social care is also acting as a rationing mechanism (CSCI 2008) which is of particular concern given the poverty being experienced by so many in face of the cost-of-living crisis, particularly disabled people. These elements all need to be considered in tandem.

While a plan develops to improve the funding situation for social care and at the same time a reframing of its contribution, Investment in building culture through shared learning and understandings of practice can help to avoid further failure demand and improve effectiveness (rather than an over emphasis on mechanisms and tools to promote efficiency).

Examples were shared from all levels of the system, including efforts to achieve mutual understanding through skilled conversations in practice; achieving better understanding and outcomes through continued dialogue between finance and practice in a HSCP; finding ways to pro-actively engage with the public to promote community based and preventative services; proactive engagement between voluntary and statutory sectors within localities to improve understanding of mutual roles, referral criteria and shared priorities. While important to promote such endeavours, it is also important to note that the greater 'volume and complexity' of need that currently exists is pushing both statutory and voluntary services towards and beyond their limits. They need to know that help is coming.

On balance, as noted in our earlier report based on the multi-stakeholder event of June 2022, most of the people who participated in that event and in this project as whole, were willing to listen to and try to understand the perspectives of others and to consider different possibilities to find ways forward. While there is no ready roadmap to navigate through the current crisis, and whilst waiting for improved funding, some partial solutions are already being developed and exist in pockets of the system. In addition, each group of stakeholders contains valuable insights and the potential for creativity with a great deal of potential through continuing dialogue to try to survive through the crisis. Without this, there is a risk of more adversarial stances and frustration and disappointment on all sides.

Beresford and Slasberg (2023) make the case that person-centred care cannot be delivered without adequate and sustained funding for social care. They are clear that the move from resource led to person centred practice is not a matter of professional choice, but must be supported effectively by systems. It is also the case that mechanisms cannot serve as a panacea in working with complex human systems, with a risk, as one contributor framed it, of mechanisms providing a 'veneer of objectivity'. There is inequity, inconsistency and lack of transparency built into and throughout the system – no mechanism can be expected to solve all of that.

Needham and Hall (2023) also usefully point to the need to acknowledge the competing paradigms underpinning social policy and how the failure to recognise, acknowledge and work through these contributes to the implementation gap of the past 25 years. One of the tensions they identify is that between a human-rights driven agenda (which requires standardisation) and personalisation (which requires a flexible and responsive approach). Well intended policy too often runs aground because of failures to engage with the complexity involved, to acknowledge inherent contradictions and to test out potential for unintended consequences. Finding ways of surfacing and working through these tensions requires continued dialogue between all partners.

A further example of where dialogue is required relates to autonomy and delegation of decision-making to social workers. Beresford and Slasberg (2023) suggest that social workers would need reskilled to achieve value for money, and there was some support for greater social worker autonomy in this research. Taking delegation further would depend on developing shared understandings about how that might work, to achieve the consistency required. The limits of this also need to be carefully considered. If social workers are viewed as the ultimate gatekeepers of social care resources, that presents its own challenges with regard to public expectations of their role, with implications for building trust and rapport. More directly relevant to eligibility criteria, dialogue is required to tackle the thorny issue of how limited resources can be distributed fairly in ways that ensure 'those who shout loudest' do not benefit most, and that the budget for social care can reach the year end.

There was support for small tests of change across partnerships in finding ways forward with alternatives to eligibility criteria. The Gateshead case study in appendix E includes examples of this. One member of the PLPP argued for research and development methods to make improvements to the system. Examples included:

• Running pilot projects to test ideas
• Learning what works and replicating that
• Start small and build (PLPP)

Such testing could include a focus on the recording of unmet need, including attention to understanding what works in improving outcomes with people, as well as the gaps with direct links to commissioning. The fear of legal challenge is one reason why unmet need is insufficiently recorded at present, and this would also need to be taken into account. To maximise potential from existing as well as any new successful methods and to promote the much sought after consistency, the fora to promote exchange of learning will be at least equally important, in moving beyond the often referred to 'pockets of good practice.'

Notwithstanding the urgent need to set out a clear plan for investment in social care in the years to come, freedom from the quest to produce a tool to replace eligibility enabled discussion about wider systems of social care, with emphasis on culture, including the way we talk about social care. This needs to be part of a wider public conversation which will be necessary to make the case for the increased funding which must follow. Also, contributors to this research identified ways of working more effectively to improve outcomes for people, engaging with complexity and navigating between paradigms. The way forward includes the creation of safe spaces for dialogue and working collaboratively to define what the right questions are, building culture while so doing.

Acknowledgements

Many thanks are due to all the supported people, carers, practitioners, managers and people from national organisations who gave their time so generously to the event described here. Although this report includes references to other reports and research, most of the ideas presented in this paper came from the people involved in the project. Thanks also to Karen Barrie who acted as a sounding board and editor. And thanks to the steering group whose ideas, sharing of case studies and healthy debate helped to sharpen the focus. Thanks are also due to the Scottish Government for funding this project.

Key findings – Challenges

• The way we talk about social care in Scotland needs to shift so that it is viewed as a solution to social challenges, not just crises
• Failure to properly fund social care across the UK over decades has contributed to the current highly problematic situation
• Eligibility criteria mask the funding gap while unmet need is not well defined or recorded. They sit some distance from fully achieving the intended objectives of equity, consistency and transparency, whilst often creating negative and exclusionary experiences for people, sometimes resulting in greater levels of need (failure demand)
• Local authorities carry legal responsibility for meeting assessed needs, and tighten eligibility criteria when they don't have sufficient budget. Whilst many acknowledge the limitations of eligibility criteria, there is uncertainty about how to make budgets stretch through the year without them, with additional potential for increased legal challenges
• If mechanisms were the answer, then we would already have equity, consistency and transparency. Solutions need to pay attention to both structure and culture in social care
• Policy has tended to ignore the tensions between standardised and differentiated/ personalised elements, contributing to implementation gaps, with a need to acknowledge and make transparent trade-offs and compromises entailed
• Spaces for dialogue have been lost since the pandemic. Opening up conversations with diverse stakeholders surfaced examples of good practice; generating fresh ideas, suggestions and examples of creative responses to crisis. Such dialogue is not just 'nice to do' and the conversations started in this project need to continue to enable people to develop mutual understanding of the complexity involved and a shared sense of purpose

Key findings – Strategies

• Separate work being planned on unmet need is critical in determining next steps as better understanding and recording of unmet need (as well as what works) could provide the evidence and point the way forward for more effective use of resources.
• Statutory and voluntary services are striving to establish/maintain early intervention and prevention. Examples include interagency approaches to community development and awareness raising (appendix D) and investment in advocacy. Efforts are underway to ensure that people who might previously have been excluded are able to access information, advice and preventative support, with posts to support this.
• More emergent approaches include greater delegation of decision-making in social work and tentative efforts to work around eligibility criteria, or push them back as far as possible e.g. appendix E. The proposed focus on human rights holds promise. These approaches, and progressive moves towards removing thresholds require to be tested in practice, to ensure the tensions identified by Needham and Hall do not result in unintended consequences, as highlighted in this report.
• Greater and sustained focus on sharing learning between organisations can help overcome gaps with implementation, spreading the 'good practice examples' as identified by Christie, Feeley and others, improve equity, consistency and transparency and help to rebuild culture lost through recent years of isolation and fragmentation.
• Striving for the wellbeing and quality of life of people who need support and unpaid carers must be kept as the primary focus despite the very significant challenges entailed. This requires continuing to involve both them and the staff who support them to work out solutions based on better understanding of the complexity involved. This will involve considerable effort and skilled facilitation to ask the right questions and effectively capture the learning.