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The Charter for the Right to Wellbeing is about transforming councils’ commissioning process. It would apply at both the individual level through service user’s support plans, and the strategic level through the contracting of provider services.
Providers do not need to be told how dysfunctional the prevailing process is;
· task and volume contracts that encourage restrictive business models
· pricing that can bear little or no relation to providers’ resourcing requirements.
Providers’ most positive achievements are too often despite, not because of, the system
It has long been said that task and volume should be replaced with commissioning based on outcomes. The change is needed to allow providers to work with the flexibility and responsiveness they know their service users need. It has also long been said that pricing should be based on a fair cost of care.
But, just as it has long been said that assessment and support planning at the individual level should be person centred not resource led, the words and good intentions have never been translated into reality other than in small and rarely sustained projects.
It is assumed the problem is cultural and behavioural;
- ‘if only professionals would let go’
- ‘if only politicians would fund adequately’.
But the root problem is systemic – the behaviours are mere symptoms of a dysfunctional system
Systemic dysfunction
The founding principle of the NHS is need precedes resource. That is not just about being free at the point of delivery. The principle has another dimension - it defines the political-professional dynamic. The professional function is to identify need, and the political function to find the resources to meet those needs.
But that principle has never been applied to social care. Since inception, resource has preceded need.
The professional function is to make need fit to whatever resource the political system happens to make available.
The individual and strategic consequences
At the individual level, calibrating need to resource firstly requires the creation of a controllable flow of demand. This requires standardised of 'need' . The flow can then be adjusted to whatever resource happens to be available locally.
There are two consequences.
The first is the long lamented depersonalisation. Despite countless 'transformation' strategies, none has succeeded.
The second is the post code lottery. Our dossier Social Care Exposed will show the true scale and consequences. After adjusting for regional price differences, in 2022/23 the highest spending 10% of councils spent £43K on average per annum on working age adults, more than double the lowest at £21K. For older people, the figures are no less shocking - £22.7K and £11.9K.
And the post code lottery affects prices. The £1,700 per week the highest spending councils pay for residential and nursing care for working age people is 30% more than the £1,300 of the lowest spending councils. The equivalent figures for older people are £809 and £980
The way councils identify needs accounts for why they apply task and volume contracts. They need providers to deliver the maximum number of standardised needs that roll off from the assessment conveyor belt as can be squeezed from the resource available.
The Charter for the Right to Wellbeing
The Charter is designed on the premise that social care must work to the same professional-political dynamic as the whereby need before resource.
It will require four steps;
1. Professionals must identify individual need against a vision of how life should be. The vision can be, and has been, described in various ways. Underpinning them all is wellbeing as defined by the Care Act. Need will be identified without regard to the availability of resources.
2. The currently available resource must be deployed to secure the greatest achievement of the vision for the greatest number of people. It will require councils to radically change the way they make decisions at the individual level given the transparent acknowledgement of need exceeding resource. And it will also require an entirely new relationship between councils and providers. Councils will look to the providers for realisation of the vision for individuals. They will need to empower providers to work flexibly - notwithstanding within a resource envelop - to respond to the uniqueness of individual needs.
This is the essence of outcomes based commissioning.
Within outcome based commissioning, the need to pay a fair price for care follows as surely as night follows day.
3. The gap between needs and resources identified at the individual level will be aggregated into publicly available information. Unmet need in social care will play the same role as waiting lists in the NHS as a public and political flag.
4. Political leaders will be exposed to their responsibility to close the funding gap and so ensure the resource envelop within which providers work is of the right size.
A new Constitution for Social Care
The Campaign believes the Charter should form the basis of a new Constitution for Social Care. It would sit alongside the NHS Constitution.
It will not require new primary legislation. Indeed, the Charter will at last mean the full and proper implementation of the Care Act.
It will not require, in itself, any more money. Just as the NHS was launched without a single new nurse, doctor or hospital, so can a principled, national social care service be launched without any new resources.
Serving powerful interests
The system has survived so long because it serves powerful interests.
First among those are short termist political interests. It keeps spending within whatever resources political leaders happen to make available, and to deny the existence of any unmet need. A need is a need only if there is resource to meet it. If not, either it becomes a mere 'want' or it becomes the responsibility of family or community regardless of whether that is right or wrong.
But it is also a system that can be used to serve commercial interests. Low profit margins at the unit level can still render good profit at the service level with sufficient scaling up of service levels.
The risks
It is not risk free. The current system is based on social care being a legal right. If a need is deemed eligible, councils are legally obliged to meet it. That sounds like good news for service users. But given it is for the council to decide if a need is ‘eligible’ in the first place – other than the very small minority who have what it takes to self advocate and know how to manage their way through the system – it’s a legal right that becomes virtually worthless.
The Charter would replace the legal right with a human right. The NHS is founded on public commitment to all having the best health modern medicine makes possible. Social care needs to be founded on a public commitment to the vision of all having the wellbeing possible for them.
Its chicken and egg. The public perception of social care is largely negative. The messaging from the system is largely responsible.
- Councils say their purpose in life is to meet ‘eligible’ needs'. But no-one has any idea what an ‘eligible’ need actually is.
- Directors at the strategic level and social workers at the individual level secure resources by emphasising lives at their worst.
- The people served are depicted as needy and dependent, not the contributing family members, fellow citizens and achieving people they wish to be and can be.
Its a turn off. The natural goodwill to our older and disabled fellow citizens and family members is untapped. The public perception of social care must be changed from negative to positive. The system itself - its professionals at all levels and its political leaders - must take responsibility to lead the change.
Without taking the risk and overcoming it, we will not have the reward of an authentically personalised system that liberates providers to work in the flexible way providers know their service users require.
The idea of a new Constitution based on the same founding principle as the NHS is surely the very stuff of the ‘deep reform’ Labour says it believes is required. The challenge is to get the idea before the Government's new Commission.