Shaping public spending priorities for adult social care

Key points

• Adult social care budgets are under ever-increasing pressure. The social care sector faces uncertainty and a series of tough decisions in the period following the Comprehensive Spending Review.
• Local authorities and service user/carer organisations alike are acutely aware that budget cuts will bring about radical changes for the sector. Many are beginning to think about the implications and plan for decisions ahead.
• While all local authorities share similar difficulties in terms of balancing budgets, individual responses to these pressures appeared to vary a great deal. Some are taking positive steps in a proactive fashion, while others are reacting to developments as they unfold. Some felt unable to plan ahead until there was clarity about the scale of cuts and wider changes such as GP consortia.
• Local authority decision-makers and service user/carer organisations shared concerns about making the right decisions for the medium and long-term. Many anticipated a dramatic reduction in funding for early intervention, prevention, and respite care in order to ensure continued support to people with the highest levels of need. This was despite their strong sense of awareness that focusing only on immediate critical needs would have negative, and costly, future repercussions.
• The research findings suggest we may see a widening gap in the performance of local authorities and the quality and range of care provided. Those already ahead of the curve are well-placed to reshape and respond, and those which are behind the curve or have weaker local partnerships will lag even further behind.

The research - By Chloe Smith and Matt Cavill, Social Research Institute, Ipsos MORI

Background

Ahead of the Comprehensive Spending Review, JRF commissioned Ipsos MORI to gain insight into how local authorities (LAs) and service user/carer organisations are thinking about and adapting to the challenges they now face. The Findings summarises in-depth interviews undertaken to explore local authority decision makers’ and service users’ perceptions of these issues. The research found that local authorities and service user/carer organisations are acutely aware that budget cuts will bring about radical changes for the sector, and many are beginning to think about the implications and plan for decisions ahead. While all organisations share similar difficulties in terms of balancing budgets, individual responses to these pressures vary a great deal. Some are taking positive steps in a proactive fashion, while others are reacting to developments as they unfold.

Priorities for spending

Statutory obligations are a key spending priority. Beyond this, there is no consensus about more specific priorities, although there is some agreement of broad themes. Many organisations are thinking about how best to reduce the scope of services that they offer and how to find more efficient ways of delivering them.

As always, our biggest focus are those who are the most vulnerable. They’ve always got to be the ultimate priority because that’s what we’re here for, to protect vulnerable people.” (LA decision maker)

Rationing access

Those interviewed say that thresholds used for assessing potential service users will need to be reviewed, so that only the most vulnerable are eligible for support. This is expected to have a damaging effect on service users. Focusing care provision only on those whose needs are already critical could prevent social care providers from intervening earlier in cases where this could prove crucial.

There’s talk at the moment about moving the goalpost to just supporting critical. All the evidence that is out there at the moment… says that in the medium term this saves you absolutely no money whatsoever.” (Service user/carer organisation representative)

Delivering minimum services

Some local authority decision makers argue that the choice they face will not be a case of adapting services, but of simply losing some services altogether. They anticipate that they would have to confine their role to providing very little beyond statutory care. The immediate impact on service users would be ‘a drastic reduction in the level of care they receive’.

Delivering services more efficiently

By contrast, others were more positive about the potential impact of the cuts, speculating that they may encourage LAs to take more imaginative approaches.

The sheer scale may force lateral thinking because it might, simply might not be possible to deal with it through standard percentages.” (Service user/carer organisation representative)

Some decision-makers are already considering how to make cuts in an innovative way. There is a general sense that there has been a move away from top-down targets towards more creative approaches to improving services, and those involved are generally keen for this trend to continue. Many LAs were already working with volunteer, community and user-led groups, with the aim of delivering the same level of service in a more efficient manner. As one interviewee pointed out, a lot of the issues currently being talked about as part of the Government’s Big Society agenda ‘aren’t anything new’, and most LAs have been fostering such partnerships for years.

New ways of delivering services

Nearly all respondents say there needs to be more collaboration between the different agencies that deliver adult social care. Several LA representatives are interested in adopting social enterprise models to build local capacity to deliver services.

It will be better for people because social enterprises can be user-led… there are lots of opportunities through having tighter budgets because it makes you do a stock take and think the unthinkable.” (LA decision maker)

Some areas are better equipped in this respect than others. Some service user/carer organisations are already working closely with local authorities to provide services efficiently, with minimal overheads.

We run independent support planning on behalf of the local authority. The KPIs on outcomes are much better than the local authority delivers… You could start to see wholesale services like that being transferred out of local authority responsibility into third sector responsibility.” Service user/carer organisation representative

New commissioning relationships

The recent health white paper (‘Equity and Excellence: Liberating the NHS’) indicates that GPs will be given greater powers over health service commissioning in future. At the time of interviewing, it is unclear exactly how the new structures will operate, but interviewees agree that it will change social care provision. The uncertainty over how the new structure will operate means that it is hard for local authorities and service user/carer organisations to plan ahead.

Some local authority officers feel better placed to respond to NHS reforms than others. Many LAs already have strong links with local GPs and healthcare services, working closely with them to meet service users’ needs. It is unclear how other LAs without this experience will fare. Some point to a perception among GPs that LAs current approach to healthcare commissioning ‘lacked professionalism’. However, they argue that GPs could learn from LAs as they take on new responsibilities.

Making the right decisions

Long-term vs. short-term priorities

The biggest concern for organisations which represent service users and carers is whether the right decisions will be made to ensure the long-term viability for social care and support in the future.

Early intervention and preventative measures are seen by many as the most cost-effective way to safeguard people’s well-being in the long-term.

If you invest in prevention then you can actually save costs further down the line.” (Service user/carer organisation representative)

However, there is fear that these types of measures will be the first to be cut if decision-makers respond to the budget cuts in a knee-jerk fashion. Not only that, the sheer scale of short-term efficiency savings could obscure the need for maintaining an approach to service provision that is sustainable in the long-term.

It will be really interesting to see whether they go for a ‘slash-and-burn’ and just trying to survive in the short-term or whether people take a long-term view of this and say we need to reshape our offer to the public.”

Service user/carer organisation representative

Some LAs are already making a concerted effort to think beyond immediate budgetary pressures by highlighting the long-term savings that preventative services can offer, and the beneficial impact that they have on service users’ well-being and quality of life.

Knock-on effects of budgetary decisions

Those interviewed point to the wider implications that short-term cuts and the current financial climate will have for service providers. For instance, they point out that, although NHS spending will be protected to some extent, the decision to cut resources for adult social care will push more and more people to rely on the NHS. This will actually create greater strain on health services, because the people turning to the NHS from social care are more likely to have complex needs.

Making the case for carer support and respite services

LA officers and service user representatives are wary of the assumption they feel some LA leaders and the national Government are prone to making: namely that families can be relied upon to step in to cover gaps in care. Some warn against cutting funding for respite care, as this will put carers under greater pressure, and undermine the sustainability of care services. In addition, the recession has affected people’s ability to pay for care and therefore it is anticipated that more and more people will have to become full-time carers. This in turn will have an impact on their physical and mental well-being.

Service user involvement

Local authorities and service user/carer organisations are faced with crucial decisions about how they currently operate and the level of services they can expect to provide in future. All saw a role for services users in how these decisions are made, though the level of involvement expected and desired varied from organisation to organisation.

Limited scope

A minority of those interviewed feel that the decision to cut funding has already been made and services will be reduced, with no time or capacity for involving service users. Instead, budgetary decisions will be taken by elected members within LAs and LA officers will have to plan accordingly, with no input from service users.

All acknowledge that choices will be limited to some extent by the budgetary strictures they will face. Therefore, while it is important to listen to the views of service users and involve them in the decision-making process, it will not be possible to meet the demands of all groups.

I know that we’re consulting on things at the moment where we are having to say: ‘Look you can have this and have that, but you can’t have all of them unless we get some core funding in play’.”( LA decision maker)

Service users’ and carers’ ability to engage in the debate will also depend on how much money and time will be available to put into communications and engagement structures required to include them. The cuts will limit the funds available to support involvement – particularly of the most vulnerable service users.

Making involvement happen

Most of those interviewed are more optimistic, and many already have arrangements in place to make sure that the opinions of service users are reflected in planning and prioritisation, and as a way of getting imaginative solutions that may otherwise not have been thought of.

It drives efficiency because they [service users] understand what is required, they can say, look I’ve been there, done it – this is what worked for me, this didn’t not work, this didn’t work for me. They can pull their experiences and their knowledge to help inform developments.” (Service user/carer organisation representative)

Conclusion

The research revealed a strong sense of the pressure that local authority decision-makers were experiencing, and uncertainty about how to make decisions that will not unravel existing good support, nor result in more unmet need and higher costs in the future. There was much trepidation, with only a proportion of local authority decision makers talking about using the opportunities created by a crisis in resources to reshape services for the better. This suggests that – in the months and years following the Comprehensive Spending Review – we may see a widening gap between the performance of local authorities in providing quality care and support. Those local authorities that are already ahead of the curve, with already strong relationships with user-led groups, providers and key agencies – will be better placed to motivate, innovate and reshape. Those currently behind the curve may be left even further behind.