A reality check on proposed social care reform

Clenton Farquharson, TLAP Chair, assesses how proposed social care reform matches up to what matters to him as a disabled person and direct payment user.

How do the plans for health and social care reform measure against my own priorities? My first observation is that there is nothing much new in the social care White Paper. It reaffirms what the Care Act was supposed to achieve, but hasn’t yet delivered - the choice and control to have high quality support organised round what matters most to the person - with wellbeing front and centre.

And in the integration White Paper there is renewed emphasis on prevention, tackling health inequality, increasing personal health budgets, and commitment to agree shared outcomes.

As statements of policy intent I get them and can get behind them. But to take them forward we need a reality check to acknowledge the distance between where we are now and where we want to be.

In social care we know councils have been held back by lack of money, but that’s not the only reason. There is too much clunky process which baffles people when they seek help and makes it difficult for people to self-direct their support.

Not everyone working in health and social care has bought into working alongside people, as opposed to the ‘gift model’ of doing things for people.

There is a risk that joining up care and health is held back, with too much time spent working out how the various pieces of the integration structure fit together. Too much commissioning still uses the currency of purchasing beds and hours.

People who draw on care and support are struggling - with a double whammy of the rising cost of living whilst having to pay more for their care.

With unmet need rising and more people due to come to councils with introduction of the cap, we cannot do more of the same. It isn’t financially sustainable and it isn’t the right thing to do. We are in a challenging place. But I am by nature an optimist; my Guinness glass is half full.

To start we need a hopeful vision

TLAP supports Social Care Future’s vision (opens new window). To help get us on the right track there is Making it Real (opens new window). This describes what good personalised and community-based care and health looks like and what organisations should do to shift towards relationship-based support focused on enabling people to lead the best lives they can.

Getting closer to the vision means a serious re-boot for self-directed support so that more people can exercise real choice and control. The number of people using direct payments is actually going down*. Whilst not right for everyone, I don’t think we have reached a natural ceiling for direct payments. TLAP has done some great work with the Local Government Association and ADASS showcasing places making progress on direct payments (opens new window). Good practice exists in pockets, but to steal lyrics from soul legend Curtis Mayfield, councils need to ‘MOVE ON UP’.  The same goes for Individual Service Funds, which allow providers flexibility to work with the person they are supporting. 

A second area for focus is what I call intentional action to close care and health inequalities. TLAP worked to find good, personalised care and support for people from Black, Asian and minority ethnic communities (opens new window). We did this during the pandemic and weren’t sure what we would find. In fact, we found many examples of innovative approaches to health and wellbeing. We also found that organisations were operating at the edge of the system. We called this ‘hidden in plain sight’. The change required is for leaders to proactively reach out and invest in organisations and types of support that show real impact, if we are going to reduce inequality and increase equity.

This leads to my third priority. We need to ramp up engagement with people and communities; co-production in other words. This means sharing power and creating a more equal relationship between citizens and professionals.

We need to create a credible approach to co-production at scale, so that people and their organisations are at the tables where decisions are made. This means investment in time and some money to create an infrastructure which is not reliant on a few voices. Co-production is not a free good. Better to think of it as an investment that will return over time.

I actually do reasonably well, not least because I can penetrate the fog of how the system works. But many people aren’t in this position. The acid test is that the next three years sees visible progress to lift the reforms off the page, with momentum and direction created for lasting change, so that person-centred care and health becomes the lived experience of many and not the few.

*Number of people using direct payments has fallen for the past four years. Fell from 123,000 in 2019/20 to 118,000 in 2020/21.  Kings Fund 360 report.