Adult social care eligibility criteria - innovations and developments: report

Considering wider evidence

Before presenting the findings from the various project engagement activities, here we refer to key texts that examine social care reforms in the UK over recent years and evidence some of the most significant implications of relevance to this project.

Systems thinking and public sector reform

The concepts of value demand and failure demand (Seddon 2008) are useful in considering how to prioritise resources and activities in the public sector:

There are two types of demand that interest a systems thinker: value demand and failure demand. Value demand is 'demand we want,' demand that the service is there to provide for…Failure demand is demand caused by a failure to do something or do something right for the customer. Progress chasing…having to bring in documents that have been brought in before, having to visit repeatedly – all of these represent demands, and therefore more work, caused by a failure of the service to work from the claimant's point of view

(Seddon 2008, p32).

Some twelve years ago, Seddon's work on systems thinking influenced the Christie Commission in Scotland, which set out an agenda for tackling public sector reform. Christie identified that the greatest challenge facing public services was to combat the negative outcomes for individuals and communities arising from inequalities (SG 2011a, p6), requiring early intervention and prevention, to avoid high levels of 'failure demand'. Christie also noted that a range of approaches, centred on collaboration and partnership with people and communities were making a real difference but remained isolated examples.

Rival paradigms in social care reforms

Exploring social care reform specifically across the four nations of the UK across the last quarter century, Needham and Hall (2023) consider implementation challenges evident in all four polities, noting that despite considerable long-term efforts, the dysfunctions of the care system remain such that all four nations are promising further large-scale reform. These authors suggest two competing paradigms predominate in social care reform.

Standardised approaches prioritising consistency with a more professionalised workforce and closer integration with health, offer one kind of care future. In contrast, approaches that seek to make care more local, differentiated, co-produced and strengths-based invoke a different understanding of what constitutes good care and a good life. In the standardised paradigm, rights are a key focus for reformers, ensuring that people have protected rights to services and funding. In the differentiated paradigm, recognition of the difficulty of enforcing rights and duties means more attention is given to personalisation, culture, relationship building and trust.

These authors examine free personal care as one example of the value contradictions that play out in policy implementation. While the principles underpinning free personal care appear sound, implementation in practice involves trade-offs and compromises: "Free personal care has focused resources on a relatively narrow set of functional supports in the home, drawing attention and resources away from investing in the local assets and networks that keep people out of the formal care system." (Needham and Hall 2023 p169). They argue that failure to acknowledge these rival paradigms is part of the reason why care reforms have, to date, faltered, and will continue to be an issue as new sets of care reforms are tabled for the future (Needham and Hall 2023 p171).

Tensions for social work

At the time of writing, a newly published evidence review has found that despite warnings over many years, the continued dominance of bureaucratic structures and managerialist policies has resulted in alienation in social work practice. The resultant experiences of ethical stress and workload pressures have "placed staff well-being on a precipice" (Pascoe et al p528). It is argued that system leaders need to work with social workers "to critically review the existing systems to reduce the administrative burdens and enable greater time for meaningful engagement with service users" (Pascoe et al 529). This echoes the earlier Setting the Bar research in Scotland (Miller and Barrie 2022) which linked workload pressures, financial drivers and administrative burdens in compromising social workers' quest to make a difference to people's lives.

While contradictions within existing eligibility criteria remained unresolved, as acknowledged in guidance for SDS (SG 2014), additional tensions for social work are contained in mechanisms for personalisation policies. Resource allocation tools (RAS) used to provide people with an initial indicative budget for their care contain contradictions. Echoing the stated intention of eligibility criteria, the RAS was promoted as being more equitable, transparent and giving people greater control over decisions about their care (Stewart et al 2021). A recent review of evidence from England Identified particular concern regarding points-based systems, with tendencies to revert to resource-led assessment and a focus on purchased resources. The lack of coverage of key areas of need for older people also raise questions about equity (Stewart et al 2021).

Social work as a profession requires engaging with complexity, as articulated in a paper published for consideration for the NCS (SG 2022a). Layering in of new legislation should involve significant testing of implications for practice. Yet, taking the case of SDS, research over many years shows that practitioners often feel they don't have enough understanding of frequently changing local and departmental SDS processes to guide service users (Ridley et al. 2012, Biziewska and Palattiyil 2022). Where a shift away from points based systems occurred, this was viewed as less 'dehumanising' (Biziewska and Palattiyil 2022, p11).

In addition to concerns about the social work profession, continuing concern is expressed for mostly female social care staff, many of whom are also experiencing work related stress and notoriously low levels of pay. Separate work has already been undertaken by the Scottish Women's Budget Group (2023) on costings for a universal adult social care service.

In turning now to consider the findings from this project, the above insights provide important anchors and can help to inform thinking about future reform, particularly with regard to eligibility criteria and their stated intentions.