Prevention is better than cure. So why are cheap preventative services, such as befriending or falls prevention so often axed, to sustain expensive crisis services such as care homes? Some areas invest in prevention and others do not. Alex Fox FRSA asks why.
The government has launched an ‘engagement exercise‘ as part of its deliberations over proposed new social care legislation. The white paper will set the government’s policy direction and respond to the recent Dilnot Commission’s recommendations on funding.
The commission concluded that social care has long been an under funded public service and its final report set out some ways to cap the amount that individuals would pay for their care in later life. Dilnot argues that limiting the risks to individuals would create the conditions in which a social care insurance market could develop, allowing us to insure ourselves against being bankrupted by unexpected care costs.
One strand of the government’s engagement strategy will generate recommendations to shift social care investment from crisis services to preventative approaches. This is welcome but difficult.
One problem with investing in prevention is that everyone means different things by the term. Many preventative services are hazy about what they are preventing and for whom. Are they trying to reduce the risk of people experiencing poor outcomes, or to reduce the use of more expensive, crisis services? How do you tell if they are succeeding? It is hard to measure things that did not happen.
Prevention needs more clarity and a better evidence base including developing ways of measuring reduced take-up of more expensive services and indicators of reduced risks, such as increases in resilience or decreases in isolation.
So successful preventative services may not be traditional ‘social care’ services such as home help. In fact some will not look like services at all. For example, inititiaves like Homeshare, where an older person who is isolated or needs a little help and has a spare room is matched with a young person who lacks affordable housing. Or time banks and care banks that bring people together with complementary support needs. Sometimes the key to a family being able to continue to care for a relative themselves is support which allows an unpaid family carer to stay in the job that keeps the bills paid and is also their break from caring responsibilities. Preventing the fall which leads to a hospital stay from which an older person never regains independence, may be down to pavement maintenance, or a befriending and shopping scheme. Tackling isolation might not involve finding a volunteer to help an older person, but helping them find a volunteering opportunity for themselves.
Richard Jones, former President of the Association of Directors of Adult Social Services, is in the process of investing £750,000 in Shared Lives in Lancashire, despite his council needing to reduce expenditure overall. In Shared Lives, an individual visits or even moves in with a registered Shared Lives carer and they share family and community life. This can often bring in unpaid support from neighbours and friends. Richard talked of a Shared Lives user who had been housed in expensive institutions: “He was desperate for a relationship because he is a human being. He’s now a godfather, he’s been to weddings; you can’t put a cash value on that, but you can measure the savings to public services.”
Perhaps none of this requires changes in the law, just better ways of measuring outcomes and proving the business case. But the new social care statute will replace current social care law – cobbled together since 1948 – with a single new law and provides an important opportunity to rethink some fundamentals. Unlike health services, mostly available for free whether you have the common cold or cancer, you have an entitlement to social care support only if your needs reach certain ‘eligibility thresholds’. Support will be withdrawn if things improve. So when money is tight, the business case for early interventions always runs up against a council’s legal duty to maintain services which meet the more acute needs of people with entitlements to support.
Could we give people rights to preventative support, based on an assessment of the risks to their wellbeing, not only on how bad things are right now? Could people be given a personal prevention budget and help to manage it? That would only work if those cheaper preventative interventions did indeed result in less use of crisis services. Perhaps we could incentivise people who use support to find alternatives to state support by sharing any savings they achieved with them, in the form of crisis or carers breaks funds.
These are radical suggestions which would carry new risks. But we cannot continue with the current system, which is arguably already bankrupt and leaves far too many people with nothing until far too late.