Missing the chance for outcome-based social care?

The draft Care and Support bill states that the aim of social care is to promote well-being. Its implementation will include new national eligibility criteria. The government is currently seeking views on a discussion document for National Minimum Eligibility Criteria. Unfortunately, as currently drafted, these criteria fail to fully support the aim of promoting well-being, and risk a generation of confusion in social care practice.

The problem is that the eligibility criteria are not outcome-based. They state:

An adult’s needs meet the eligibility criteria if those needs are due to a physical or mental impairment or illness and the effect of such needs is that the adult—

  • is unable to carry out one or more basic personal care activities and as a consequence there is a significant risk to any aspect of the adult’s well-being;
  • is unable to carry out one or more basic household activities and as a consequence there is a significant risk to any aspect of the adult’s well-being;
  • is unable to fully carry out any caring responsibilities the adult has for a child;
  • needs support to maintain family or other personal relationships, and a failure to sustain such relationships has or is likely to have a significant impact on the adult’s well-being;
  • is unable to access and engage in work, training, education or volunteering and as a consequence there is a significant risk to any aspect of the adult’s well-being; or
  • is unable to access necessary facilities or services in the local community and as a consequence there is a significant risk to any aspect of the adult’s well-being.

If the overall goal is to promote well-being, then eligibility criteria must be based on the minimum outcomes that are required to achieve an essential standard of well-being. If these minimum outcomes are not met, people are not achieving well-being. That makes them eligible for means-tested funding, and help to arrange care and support.

The minimum outcomes already exist. The Adult Social Care Outcomes Toolkit (ASCOT), developed by the Personal Social Services Research Unit, sets out the domains that social care is concerned with and an outcome for each domain. These have been tested and used with service users nationally.

Based on ASCOT, the minimum outcomes would be:

  • "I can choose what to do and when to do it, having control over my daily life and activities.
  • I feel that I am personally clean and comfortable and look presentable.
  • I feel that I have a nutritious, varied and culturally appropriate diet with enough food and drink that I enjoy at regular and timely intervals.
  • I feel safe and secure. This means being free from fear of abuse, falling or other physical harm and fear of being attacked or robbed.
  • I am content with my social situation, where social situation is taken to mean the sustenance of meaningful relationships with friends and family, and feeling involved or part of a community, should this be important to me.
  • I am sufficiently occupied in a range of meaningful activities whether it be formal employment, unpaid work, caring for others or leisure activities.
  • I feel that my home environment, including all the rooms, is clean and comfortable."

Eligibility would be based on whether someone was achieving these outcomes or not.

 

That's not all, though. The draft National eligbility criteria aim to do some other things that are required by the draft Care and Support Bill:

  • Ensure that people get advice, information, and access to other services in a joined-up way
  • Include consideration of people's strengths
  • Promote equality for people with fluctuating needs and for carers.

I think these areas can be met if the eligbility criteria state that:

"People are eligible for care and support if one or more of the minimum outcomes are not being met consistently, or are reasonably likely not to be met at an identifiable point in the future

And  the outcomes cannot be met by advice, information, access to universal services, or access to services other than social care

And the person is not able to:

  • Achieve the minimum outcomes themselves
  • Achieve the minimum outcomes without pain, distress or anxiety
  • Achieve the minimum outcomes without putting self or others at risk
  • Achieve the minimum outcomes in one area without detracting from another area of well-being."

This would apply to all citizens - service users and carers. It woudl significantly simplify the criteria.

 

The move to outcome-based eligibility criteria is quite a significant one. However, the draft Care and Support bill, and policy of recent years, already demands a focus on outcomes in assessment. Having eligibility criteria that do not fully support this will result in some adverse consequences:

  • Complicated assessment processes where assessors have to translate needs-based eligibility into outcomes
  • Care and support plans being written in the language of needs rather than outcomes
  • Confusion about the level to which well-being should be promoted
  • Confusion about how much preventative care and support is enough
  • Costly court cases to establish whether local authorities promoted well-being sufficiently, or prevented needs for care and support sufficiently.

This is an opportunity to reach a consensus on what social care is for and what standard of well-being citizens are entitled to. We can do this by basing eligibility on the minimum outcomes that are required for an essential standard of well-being. These outcomes can be relevant to all, and promote equality for all service users and carers. They can support assessors to be forward-thinking about threats to well-being and to act preventatively.

If this opportunity is missed, then it will result in ongoing confusion about outcomes and about the role of social care, and this opportunity will not come up again for a long time.

 

Discussion document on the draft National Minimum Eligibility Criteria

Adult Social Care Outcomes Toolkit