A Route to Removing Conditionality in Adult Social Care?
One of the highlights of 2019 for me was the Social Care Future (SCF) event in Birmingham. Held at the University, the discussions nevertheless included a wide range of people from some very different backgrounds, ranging from service providers and commissioners to people who use personal budgets. I found the conversations fresh and informative, and I’d encourage anyone who can to get involved.
There are a lot of different networks currently trying to think past the deadlock in adult social care. In England we have seen a decade of systematic disinvestment in state-funded care, with results that no-one sees as positive1. Across the political spectrum people have been putting forward ideas for what should happen next. Last year, the Prime Minister was forced to admit that the ‘fix’ he had promised when he first came into office was probably still five years away, in part because of the political divisions over the issue. Yet another attempt to find a cross-party consensus is now underway. Amongst policy nerds, there is general agreement that any solution will inevitably involve more resources (whether as time given freely or paid for), and a lot of the wider debate has got stuck on the specifics of this2. Discussions about adult social care parallel wider debates about the role of welfare, where a similar impasse has been reached. One idea that’s been around since the 1970s has recently been receiving renewed attention. Universal Basic Income (sometimes known as citizen’s income) proposes that every adult should receive an amount of money sufficient to meet their basic needs. Last summer the Social Prosperity Network put out a discussion paper about a variant on UBI, which they call Universal Basic Services (UBS). At the Birmingham event, I was struck by the compatibility of UBS with some of the approaches developing withing SCF. This blog is my attempt to sketch out some of the common ground.
For more than a year, SCF has been hosting events like the one in Birmingham, and publishing individual blogs about what the future might look like (you can read mine here). Back in October, SCF published their first report — Talking About a Brighter Social Care Future. As well as involving a wide range of stakeholders, one of the key features of the SCF approach is to develop an idea of what should change alongside a clear strategy for how it can happen. The report sets out the broad parameters of this strategy:
“These centre upon the importance of how issues are framed, upon the careful selection and deployment of values in the messages we deliver, on the importance of inspiring hope and possibility, including both by offering a positive vision of the future as well as by spelling out the concrete solutions, that will take us there”
A consensus vision of the future has been slowly emerging, and perhaps because of this, a lot of the debate at the Birmingham event switched back to how we can make it happen. One of the difficulties of the current system is the way care is rationed. In one discussion group we talked about the toxic effects that this has on the relationship between professionals (such as local authority social workers) and the people they are trying to help.
“Ideas and discussion about social care are nearly all based on what has been called a “professional gift” approach, with low expectations of those older and disabled people needing support, which can be stigmatising.”
Notes from the Birmingham SCF Event, Mendonça 2019
For many years social workers have been trying to move away from this and assess people’s needs in a way that emphasises their strengths and capabilities3. Despite widespread acceptance that this is a better approach, statutory guidance issued under the Care Act 2014 still requires an assessment of what people can’t do4 before local authorities are allowed to pay for anything or provide services. Even where the assessment is ‘successful’ in terms of demonstrating that the threshold has been reached, the focus on deficits often becomes an obstacle to the next task — support planning. Good support planning sees ‘care’ as one way of helping people to do whatever they want to do with their lives, rather than fixing (or compensating for) whatever’s ‘wrong’ with them. But assessments that focus, for example, on whether people can use local shops and services without help, tend to lead to support plans that focus on shopping, rather than playing an active part in families and communities. To summarise, making people ask for care and placing social workers (and other professionals) at that gateway causes at least three major sets of problems:
- It positions professionals and the people they are there to help as opponents in a game where ‘winning’ is getting access to funding (or preventing people from getting it);
- Requiring people to ask for help can make them feel powerless and worthless, and requiring them to emphasise how weak and helpless they are only makes this worse (no matter how well-intentioned or skilfull the assessor is).
- Success is rewarded with ‘care’ that doesn’t recognise people’s aspirations for their own lives.
Any vision for a better social care future will have to tackle these problems. And of course it doesn’t have to be this way. For a start, GP consultations don’t begin with an assessment of eligibility (at least for people with UK residency). This might be one reason why, according to the 2018 British Social Attitudes Survey, NHS primary care services enjoy a 63% satisfaction rating compared to 26% for social care.
The situation with primary healthcare and adult social care mirrors others in a number of different policy areas, which also differentiate between universalism (everyone gets it) and conditionality (you only get it if you meet certain criteria). A good example is the benefits system, which in the UK has seen a slide towards conditionality over the past 10 years. This change has taken place despite growing evidence that conditionality does not help people into/back into work, and instead has a number of unintended negative outcomes ranging from declines in health and wellbeing to the growth of ‘survival crime’. In social care as well as the wider welfare system, we need to be moving away from conditionality and towards universalism rather than the other way around. Universal Basic Services is another attempt to develop thinking about how this could be achieved.
The idea of a Universal Basic Income has been traced back to George McGovern, the Democratic Candidate for the 1972 US Presidential elections5. He suggested a $1,000 basic income for every adult, to be funded from general taxation. One problem with this approach is the sheer level of finance required, which means income-based taxes would need to be raised enormously to give people even a very moderate income. This can be partly solved by making UBI taxable, but this only works if the whole welfare and taxation system can be reformed at the same time, which doesn’t seem realistic6. Another problem with UBI is it assumes that ‘basic costs’ would be the same for everyone. Any standardised UBI would fall far short of what most disabled people would need to pay for their own care and support, which would mean it would need to run alongside current disability and sickness benefits rather than replacing them. If implemented in this way, UBI would no longer be a solution for conditionality.
Substituting Universal Basic Services for UBI can potentially solve these problems, as well as some of the other growing problems with the current welfare system such as the adverse effects of precarious employment (for example as an agency care worker). Firstly UBS could be implemented incrementally; we already have universal healthcare, and the cash benefits that pay for other basic services could be removed at the same time as free services are introduced. The paper published last summer uses information technology, transport and housing as worked examples. Transport is something that people need to participate socially, but also to engage with employment. Providing basic transport that is free at the point of use therefore has the potential to improve both social cohesion and productivity, as well as having secondary environmental benefits by reducing greenhouse emissions. With public transport, accessibility is designed in (for example in terms of accessible doorways and wheelchair bays) and the costs are shared equally, rather than loaded onto the individual transport user. This solves the problem of having to decide how much money is enough to meet people’s basic needs by meeting them directly. This is the problem faced by many disabled people, whose PIP and adult social care budgets have been reduced to the point where the additional income available from employment is no longer sufficient to meet the costs. Providing free support at the point of need would enable people to continue to participate in work and other aspects of community. A key feature of UBS is the way that is raises the ‘floor’ of support for everyone, instead of focussing on the marginal costs for individuals. This is important both in terms of its effects and the way it frames the role of the state.
“…ensuring that every citizen has access to a basket of basic services that enables them to participate in society is consistent with a “capabilities” approach to inequality; that is, the role of the state is to ensure an equitable distribution of not (just) money but opportunity to participate and contribute to society.” P.23
An innovative feature of the SCF approach is the application of framing theory, as developed in the UK by the Joseph Rowntree Foundation and the Frameworks Institute. From this perspective, every policy objective is ‘framed’ either implicitly or explicitly, by different sets of values. The values that underpin conditionality hark back to the 19th century poor laws and the deserving and undeserving poor. These have been exacerbated by the post-2008 rhetoric of affordability that has underpinned the subsequent policy of austerity. Within this frame responsibility for poverty is located within individuals, and collective responsibility for providing relief and finding solutions is limited. The values that frame universalism relate more closely to social justice and equality7. These are clearly common to UBS and many of the ideas growing out of SCF. Finding common values is important for at least two main reasons. Firstly, framing theory suggests that once people accept a set of values as being a good way to understand one social issue, they are more inclined to see other issues from the same perspective. Secondly, when diverse groups of people start to align their value frameworks, this creates the necessary pre-conditions for social movement building8. The discussions in Birmingham ended by drawing together some ideas for how we can build a social movement. From my perspective this involves developing links with ideas like UBS and the people who are pushing them, as well as within the smaller pond of people focussing on social care. Adult social are could easily sit alongside healthcare and the other basic services suggested by the Social Prosperity Network, and universal access and the removal of conditionality is consistent with the vision of a brighter future emerging within the SCF.
These are only first thoughts, really, and there are a lot of rough edges. The main difficulty is how you set up universal services without returning to a top-down, state-run bureaucracy. I don’t think this is inevitable at all. I have some preliminary ideas, and if this post gets enough interest I’ll post a follow-up.
Jon Hyslop 17/3/20
- Approx. half a million people who would have received support in 2010 were no longer eligible by 2015, alternative funding schemes based on increasing local taxation have not worked, and companies providing care have been going bust.
- For anyone who’s interested, I wrote a long blog in back in 2017 explaining the difficulties with the current funding model and with the main contenders for a replacement
- Saleebey, D (2001) Practicing the Strengths Perspective: Everyday Tools and Resources. Families in Society: The Journal of Contemporary Social Services 82, 221–222. https://doi.org/10.1606/1044-3894.195
- Her Majesty’s Government (2015) Care and Support Eligibility Regulations: England. SI 2015:313
- See Atkinson, A.B (2015) Inequality: what can be done? London: Harvard University Press, pp. 218–222 for details.
- See Spicker, P. (2019) Some reservations about basic income, for a fuller discussion.
- Schwartz, S.H. (2006) Basic Human Values: theory, measurement and applications. Revue française de sociologie, 47: 259–288. Cited in Talking About a Brighter Social Care Future.
- Johnston, H., Klandermans, B. (Eds.) (1995) Social movements and culture. Minneapolis: University of Minnesota Press.