By Simon Bottery, senior fellow, The King's Fund
A key benefit of a wide-ranging review like Baroness Casey's Independent Commission into Adult Social Care is that it can look at the big issues in social care and evaluate radical proposals to see whether they have merit.High on the Casey Commission’s list should be to look at our approach to assessing people’s finances and social care needs and consider whether doing this nationally would be fairer and more effective than asking each of the 153 local authorities to do it, as is now the case.
There are several reasons why this might be a better approach.
Why a national assessment system may work better
First, there is plenty of evidence that the current system has led to local unfairness. In some local authorities, four times as many older people receive publicly funded care as in others. While some of this variation may be down to differences in demographics, it is also likely to reflect rationing of care by some cash-strapped local authorities. That would not be possible with national assessment.Second, it seems plausible – at the very least – that money could be saved by having national assessment rather than duplicating the process in each individual local authority.
Third, national assessment would allow social care assessment to be better co-ordinated with national disability benefits. It would create the potential for a benefit like attendance allowance to offer earlier, preventive support to people who do not yet qualify for formal social care services.
Challenges of a national approach
The commission should also of course consider the challenges that would be presented by what would be a very significant change.National assessment works well in other developed countries with social care systems that are often cited as exemplars - Germany, Japan and, for working age adults, Australia. However, it is based upon assessment of people’s level of disability, which – in theory at least - is different to the outcomes-based assessment approach used in England.
Would such an approach work in England? Would it be supported by people who draw on services?
Other issues to consider include how national assessment would work alongside local commissioning and provision of support services and whether it would also require national funding of social care support, rather than each local authority deciding its own social care budget.
Six key problems facing social care...
National assessment is just one of the ideas that emerged from workshops held by The King’s Fund earlier this year to identify potential solutions to the problems facing adult social care. We think there are six basic problems: access, quality, workforce pay and conditions, market fragility, disjointed care and the postcode lottery (the one which national assessment most obviously addresses).In a recent paper, The King’s Fund explored these solutions and then set out those for which we think there is strongest evidence or – as with national assessment – a good reason to explore them further.
...and potential solutions
Some of the other conclusions we reached include that:- Introducing wider eligibility for publicly funded social care is essential to ensure greater equity of access to services, minimise catastrophic costs faced by individuals and reduce friction between the health and care systems. While a free at point of need, NHS-style social care system is likely to be unaffordable, options such as free personal care, as in Scotland or a social insurance model, as in Germany, need exploring.
- There are no simple shortcuts to improvements in quality, but at the heart of any solutions should be measures to improve the choice and control that people have over their care, which will require a change of culture in some providers and local authorities.
- The government’s proposed fair pay agreement is a genuine opportunity to improve workforce pay, but will need to be fully funded and co-ordinated with wider reform of social care.
- Local authority spending power needs to reflect not just the direct costs that local authorities face but also the indirect costs, particularly the costs of commissioning social care.
- A review of NHS continuing healthcare, which plays an important and overlooked role in social care, is urgently needed.
- A new ‘social contract’ between the individual and the state on social care requires better knowledge about what happens at the moment, including an up-to-date assessment of the extent of out-of-pocket payments by individuals and the extent and costs of third-party top-up fees.
The need for compromise
Tackling all six of the basic problems we identify will be a huge task for the Casey Commission and the social care sector will need to accept that it cannot have all it wants immediately.Compromises will clearly have to be made to come up with an affordable, sustainable solution.
Nonetheless, exploring radical ideas like national assessment, if they appear to have merit, will be a good starting point.
