Ensuring the outcome measures in the Adult Social Care Outcomes Framework (ASCOF) are “relevant and meaningful to the public” was one of the tests laid out by the Department of Health.
Domain 1 of the ASCOF is, in a number of respects, the most personal and relevant of all. Losing control, independence and quality of life is one of the biggest fears people face when coming into contact with care services. For example, the fact that dementia is feared more than any other illness amongst the over-55s is in no small part due to the devastating impact the disease can have on a person’s independence (something recognised in the Prime Minister’s National Dementia Challenge).
That Domain 1 contains 50% of the 16 indicators within the ASCOF is both a reflection of its importance, but also the wealth of existing information there is to measure improvements in this area (and perhaps the paucity of indicators in other domains) – for example the level of support provided to allow people to be cared for in their own home.
So delivery on Domain 1 of the ASCOF will, as with its equivalent in the NHS Outcomes Framework, be a key test of the effectiveness of the Government’s reforms.
Firstly, supporting people to live in their own home has been one of the most emotive issues relating to the debate surrounding the social care system. Stories of the elderly having to sell their own home regularly feature in newspaper headlines as an example of an unfair care system. As has been already been discussed on this blog, social care funding is, and will continue to be, a controversial issue. Many people object to the concept that people may be forced to sell their own home to pay for care costs, yet there is also a justifiable reluctance amongst some, including senior politicians, to meet the long-term and significant costs associated with social care through taxation.
An atlas of variations in social care found a seven-fold variation in the proportion of older people assessed with care needs being supported to live in their own home through homecare of over ten hours a week. The reason behind this variation is unclear but differences in eligibility criteria and assessment processes will play a role. It is encouraging, therefore, that within the Care and Support White Paper, the Government has committed “to introduce a national minimum eligibility threshold”. Based on the recommendation made by the Law Commission, this, when introduced in 2015, will bring about much greater consistency in access to care across England and address the existing postcode lottery. Plans to ensure all carers can access an assessment could likewise improve their quality of life. The challenge for local authorities will be to deliver this care at a time of belt tightening, which as the Prime Minister re-iterated last week, is likely to go on for many years to come. An assessment and minimum entitlement is all very well, but only if high quality services are available to address the needs identified.
Secondly, where an individual dies is also an indication of whether care services are personalised and people are receiving the level of care necessary to allow them to stay in their own home. Over the past few years, there has been a strong emphasis by Government on ensuring people have the opportunity to die in the location of their choice, including in their own home. The 2008 End of Life Strategy illustrated this national commitment by including survey results which showed that over 70% of people want to die at home. Instead, our research has found that between 2008 and 2010 only about 20% did with 50% dying in hospital.
What this illustrates is a clear divide between national ambition and local delivery. Helping people to be cared for at home could help local authorities to deliver significant financial savings while at the same time improving the quality of services. It is encouraging to see the Department of Health has agreed in principle of providing free end-of-life care and announced pilots to test this proposal. However, the challenge with tariffs is never the principle but the implementation. Once the findings from these pilots are available, local authorities should consider our recommendation for local accounts to include details of how they intend to deliver the End of Life Care Strategy.
Thirdly, by its very nature, social care is an incredibly complex system to navigate, with people’s support needs dependent on any number of personal factors and preferences. It is for that reason that the Department of Health (under both Labour and the Coalition) has sought to expand the use of personal budgets and direct payments within social care as a way of giving people more control over their care. Indeed, the Coalition’s Care and Support White Paper commitments to “legislate to give people an entitlement to a personal budget as part of their care and support plan”, and extend the use of direct payments. However, while some believe personal budgets to be a useful tool to promote independence, others have raised legitimate concerns about whether people will be well placed to understand what the money should be spent on and the extent to which they improve an individual’s quality of life.
Evidence from our research would seem to support this uncertainty by revealing very little correlation between the amount that local authorities spend and the extent to which people feel as ‘in control’ of their lives as they would like. What this would suggest is much more work needs to be done to ensure people have access to the right services but are also able to understand the tools available to them. As part of this, the Department of Health should conduct an audit of how personal budgets and direct payments are currently being deployed in order to inform this work ahead of them being rolled out in full in 2013. The Government’s commitment to establishing a national information portal about care and support, and plans to support local authorities in improving access to information is, therefore, encouraging. Information on social care is patchy and this can be a real barrier to people accessing services they are entitled to.
Improvements in Domain 1 will help improve the quality of life for those accessing care services and allow the Government to demonstrate success in bringing about a more personalised care service which empowers people and helps them to maintain their independence – a key objective of the much delayed Care and Support White Paper. But this will be a challenge. The picture today is of substantial variation, poor correlation between service delivery and quality, and a postcode lottery between 152 different care commissioners. However, as highlighted here, the proposals laid out in the Government’s reforms do present an opportunity.
What is needed now is national leadership to implement these reforms, even while clarity on funding remains elusive. Without improvements in quality, it will be difficult to forge consensus on how best to pay for increased entitlements. Unless progress is made on Domain 1, the Government risks leaving social care, and its reforms, out in the cold.