Needs that fall on deaf ears: As the way we care for the elderly and disabled changes today, Rosie Waterhouse explains why they may be cheated

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The Independent Online
A NEW system for looking after the social welfare of millions of elderly, disabled and other vulnerable people begins today, introducing changes as radical as those that have been sweeping through the National Health Service.

Community care, as it is known, could be a shining example of how civilised societies care for their more dependent members, enabling them to live as independently as possible, in their own homes, if feasible. The way community care is being implemented, however, has drawbacks. The method of funding is one. The funding formula heavily favours the shire counties, which have lots of nursing and residential care homes, and does little to meet other needs.

The amount of money allocated is also likely to prove inadequate. Although health ministers insist that the pounds 565m government grant to local authorities to deliver community care is sufficient, 80 per cent of directors predict their money will run out. The fact that councils are required to spend 85 per cent of their funds in the private sector, and that most private provision is in residential care and nursing homes, means there will be little cash left for the promised new services to help people to stay in their own homes and provide temporary care to give relatives and other carers a break. Another potential problem is that in future years community care budgets may be raided to pay other council bills, as the protection of 'ring fencing' - which protects the funds from other claims - is removed over the next four years.

Optimists hope that the principles behind the policy will eventually improve the lives of millions of elderly and infirm people, and those of their carers. This week, however, it has emerged that one of the most important tenets of the arrangements is being subverted by mean-spirited official circulars giving guidance that amounts to encouragements to social services staff to be dishonest. The advice is clever, cunning even: it shows social services directors how to get round their obligations, but in a way that can only disadvantage the clients they are supposed to be caring for.

Rather belatedly, officials realised that the community care policy, as outlined in the 1989 White Paper Caring for People: Community Care in the Next Decade and Beyond (that is, the provisions which come into force today), made promises that no local authority could deliver in full without a blank cheque from the Treasury.

This they were unlikely to be given, as one of the main intentions of the policy was to relieve the Department of Social Security of what had been an open-ended commitment to pay for social care such as places in residential and nursing homes and certain benefits for disabled people. The Department of Social Security bill for accommodating people in private homes increased from pounds 10m in 1979 to pounds 2.5bn this year. Now the responsibility - and future expense - has been transferred to local authorities with a fixed government grant to help to finance it.

Last December, Herbert Laming, chief inspector of the Social Services Inspectorate, warned that councils could face legal action if they informed people about the services they needed and then failed to provide them. After frantic requests from local authorities for the advice to be clarified, David Lambert, an assistant chief inspector with the Inspectorate, offered two solutions.

First, he said, the local authority could record 'unmet choice': in other words, recording what the individual wanted without conceding that this was a 'need' which, for whatever reason, could not be met. Alternatively, the local authority could make a clear distinction between the process of assessing an individual's needs and the planning of services. There would be a 'service deficiency/improvement' document, for internal purposes only, which would invite the assessor to speculate what services might have been appropriate without indicating that they were necessary, thereby implying that the services were deficient.

Such disingenuous advice sends all the wrong signals to those who are supposed to supply community care. The Association of County Councils reports that some authorities are not carrying out formal assessments of clients' needs; instead they do a 'review of circumstances'.

This less-than-candid attitude at the top has already had an influence on the social workers and 'care managers' whose job it is to interview people, assess needs, (supposedly taking into account personal preferences), plan appropriate services and make arrangements for those services to be bought, mostly from the private sector.

A report published on Monday by the Joseph Rowntree Foundation on how assessment procedures, already introduced, have been working in practice, confirmed the worst fears of what could happen after community care is fully implemented today.

After eight months studying how the needs of disabled people in a metropolitan borough and a shire county were assessed, Kathryn Ellis, a researcher from Birmingham University, found that social services staff were secretly rationing the care and services available. Instead of advising clients of the full range of services that community care was supposed to deliver, the assessors tried to identify 'undeserving cases'; failed to suggest services they thought would be too expensive or difficult to provide; and disguised the fact that services were being rationed, making it impossible for clients to challenge their decision.

In a withering indictment of the so- called caring profession, the report concluded that social workers exploited most users' lack of knowledge as a way of limiting the assistance on offer; placed a high value on their own professional judgements and devalued the views of users and carers; overestimated the preparedness of users' relatives and friends to provide care; and could be particularly insensitive to members of minority ethnic communities.

Undermining the principle of user choice, assessors treated disabled people who appeared knowledgeable about their entitlements as 'demanding', while those who tried to exercise choice or challenged the social workers' judgements were regarded as 'fussy' or 'manipulative'.

As a result of all this, what might have been a cause for celebration today - a relatively smooth transition to community care - has been soured by a last-minute confrontation between social services directors and the Health Minister Tim Yeo.

Stung into action by the Rowntree report, the Association of Directors of Social Services fired off a press release on Monday condemning the Government's 'unrealistic' guidelines on how assessments should be carried out and how unmet need should be recorded. The association argued that the advice issued so far was 'not sufficiently precise'. Peter Smallridge, ADSS president, said: 'Not to record unmet need puts staff in an impossible position and runs contrary to the spirit of community care.'

The minister responded with not one trace of sympathy for the social services directors' dilemma. 'Guidance cannot be used to duck decisions that will have to be made at a local level,' he said. 'Assessment is about discovering what a person's essential needs are, it is not an exercise in drawing up a wish list. Asking social workers to produce a list of services that might be helpful without any thought for resources or priorities would be to ignore reality.'

Such hard-headedness does little to foster any genuine commitment to the brave new world envisaged by Sir Roy Griffiths, former Downing Street adviser on health, when he created the concept of community care in 1988. No wonder that in recent speeches Brian Mawhinney, another Health minister, has warned social services managers not to build up expectations. 'April 1993 will not usher in Utopia,' he has warned.

(Photograph omitted)

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