Strengths-based approaches and the Care Bill: the next steps
The scale of the current challenge
“I shouldn’t have to spend my life proving that my son can’t do things, to get the support my family needs to help him do things for himself.”
Unpaid family carer.
This quote from an unpaid family carer illustrates the catch-22 situation which many people accessing social care have faced for years and many more face as resources get ever scarcer; social care is supposed to help people to achieve well-being, but accessing social care can involve a process which is demeaning and undermines people’s independence. The means test involves demonstrating lack of money. The eligibility test involves proving people have a high level needs and minimising an assessor’s understanding of their strengths, skills and informal support networks.
We have argued in reports including Reforming the front of social care that, whilst people go into social care careers from a desire to help and empower people, practices which harm rather than help older and disabled people are embedded in the ‘gate-keeping’ approach to social care, and are further exacerbated by constant pressure to make short-term budget cuts. Rather than starting by asking what services people need, we believe in asking people, ‘What is your vision for a good life and how can we get there?’ Rather than waiting for people to fall into crisis, we believe in investing in helping people to stay strong and connected.
Reforming this system and changing the culture it has spawned was never going to be straightforward. Well-intentioned attempts to revise Fair Access to Care eligibility rules have simply seen the scope within those rules to take a holistic view of people and to support them in their family and community relationships ignored. The vast contribution of family carers has remained ignored, until it can be exploited.
A number of commentators have pointed out the risks involved in introducing ‘strengths-based’ or ‘asset-based’ thinking (looking first for what people can or could do, before looking at what they cannot do) into currently dysfunctional statutory processes such as assessment, eligibility testing and resource allocation. They highlight the fear that this thinking is a poor fit with bureaucratic processes and may simply create a new language to be used by systems which remain focused upon retaining power within existing bureaucracies whilst cutting essential services.
The common ground
The principles of taking strengths-based approaches and investing in strong and resilient relationships, families and communities are uncontroversial. The question facing us in the light of the language of strengths and assets making its way from the White Paper vision onto the face of the Care Bill itself, is how best to start making that culture shift whilst minimising the risks and unintended consequences which accompany any radical change. Should strengths-based approaches be embedded in statutory assessment and planning provisions, described in regulations and statutory guidance, or kept firmly in the realm of good practice guidance?
Tinkering with the mechanics versus real culture change
The Bill has most noticeably introduced the language of asset-based approaches into the revised description of the four aspects of an individual’s life and prospects for future well-being which make up the new ‘needs assessment’ (Clause 9i). The retention of the language of ‘needs assessments’ points to the limitations of this change. The regulations and guidance following the Bill will need to make clear that continuing with the current mechanisms and assumptions embedded within the concepts of assessment, but attempting to make that assessment more comprehensive, will not create real change. In fact, as we have seen in some areas with poor implementation of Resource Allocation Systems, a change in mechanism without a change in attitude, can lead to the new jargon and processes being used as new, more Orwellian, barriers between people and the support they need.
Families providing unpaid care and sometimes grassroots groups who provide support are being exploited within the current system in some areas. We do not wish to see the language of strengths and assets approaches becoming a new cover for that exploitation.
To move towards a genuine strengths-based culture, processes which help people to understand their situation, options and possibilities should be removed where possible from state control. This suggests a separation between interventions designed to help people plan to achieve outcomes and interactions needed to determine eligibility, which may mean that holistic assessments are carried out as supported self-assessments where people wish, or are facilitated by workers and agencies independent of state control.
Many people who could benefit from support to understand their options and to plan their lives have no eligibility for state support. It is particularly nonsensical to offer planning support to those people only in the context of a system whose primary purpose is to restrict resources. However, the principle of separating support and resource-authorisation roles applies to people with every level of need. For instance, accessible information about choices, support to self-advocate and independent advocacy should all be widely available, so that those least able to make informed choices can and do access their rights and achieve their desired outcomes.
Strengths-based approaches suggest lowering eligibility criteria
The risks of changing the language whilst retaining the same culture can be seen in some of the recent debates about where to set eligibility criteria. Some have argued that it would be acceptable to raise eligibility criteria, as more people will be successfully supported by their communities or families, rather than needing the services traditionally offered to those deemed eligible for care and support.
It is true that, where a person and their support networks are well-understood, valued and supported, that person may be less likely to rely upon traditional services for certain aspects of their support. For instance, someone with mobility issues who has been isolated might be supported to reconnect with friendships and their community through support to access community transport and community-based support, rather than a day centre. But closing an existing traditional service will not result in the growth in that person’s informal networks, without well-resourced and planned work to achieve that goal. Strengths-based interventions require resourcing. Services of all kinds are transforming themselves to take a more enabling, empowering and networked approach.
Furthermore, whilst eligibility criteria determine that an individual is eligible to receive support, there is no simple correlation between a high level of support need and a particular kind of service. As outlined above, for the individual to plan creatively and with freedom, they may need planning and choice-making support which is independent of the eligibility assessment process. People will need to be sure that they can fall back upon clear support entitlements, if they are to feel safe exploring non-traditional approaches.
The creativity and imagination implicit within a strengths-based approach is not easy in a climate of fear, which is how many people who rely on services experience the current cuts. High eligibility thresholds increase the number of people who fear for their essential support and increase the time and energy spent by people and their advocates in battling for that support. Conversely, a system which has something of value to offer to a much wider group of people is likely to lead to much greater creativity. Well-supported families and informal support networks, who feel that they have back-up from services available if they need it, are more resilient and more likely to connect with those around them, whereas families struggling to remain financially or emotionally sustainable are more likely to turn inwards and to collapse.
It has been an apparent paradox within the current system that ever-rising eligibility thresholds have led to ever-rising costs of care. Conversely, to result in genuine increases in the value of family and community contributions, local decision makers will need to demonstrate their trust and willingness to risk-share through lowering eligibility thresholds alongside increasing the range of approaches on offer.
Co-production is key
The debate about social care transformation at both national and local level remains one which is dominated by the voices of government and commissioners, with some input from better-resourced providers. Local decision makers are still too often deciding to close buildings-based services and then to consult their users about those decisions, rather than having a multi-faceted and open conversation with people and communities about the future of the buildings, services and relationships involved.
This is reflected in decisions taken en masse about individuals’ support packages, according to new criteria set centrally. These decisions leave people feeling powerless and more fearful. Families feel that their support is taken for granted. In contrast, every truly effective social care intervention leaves an individual better informed and connected and more confident. Every intervention should support the individual’s unpaid relationships and informal networks of support and be designed to avoid undermining key relationships or isolating the individual from natural support networks.
It is even rarer for the wider community to be engaged in the co-design of care and support for the area. Well resourced ‘asset based’ community development, through well-tested approaches like Local Area Co-ordination, is vital, if communities are going to play a more active role in both supporting people and in ensuring that people with support needs are valued as active citizens who have something to contribute.
Everyone involved in care and support will need training and support to think and act in ways which build resilience, rather than acting as gatekeepers. Many social workers are frustrated with the current confines of their roles and would welcome the opportunity to get back to the role they trained for. A strengths-based approach should not mean providing traditional interventions using workers with fewer qualifications or volunteers in place of paid staff. This is likely to be the worst of both worlds: a ‘gift-model’ service without the necessary resourcing. Volunteers have huge amounts to contribute in other ways and their goodwill should never be exploited.
Families already contribute care valued at billions of pounds. Unpaid family carers can only contribute care sustainably when they do so out of choice, not when there are no alternatives. For caring to be sustainable, families need to be able to maintain a viable family income and to access the information, breaks and support they need to be confident in their caring role.
Decision makers who genuinely believe in ‘social capital’ will need to demonstrate the value they put on the non-financial resources which individuals, families and communities have to offer through involving citizens at every stage of the decision-making and commissioning cycles.
i Clause 9, subsection 4:
A needs assessment must include an assessment of—
(a) the impact of the adult’s needs for care and support on the matters specified in section 1(2),
(b) the outcomes that the adult wishes to achieve in day-to-day life,
(c) whether, and if so to what extent, the provision of care and support could contribute to the achievement of those outcomes, and
(d) whether, and if so to what extent, other matters (including, in particular, the adult’s own capabilities and any support available to the adult from friends, family or others) could contribute to the achievement of those outcomes.
This publication is jointly published by:
Partners in Policymaking
Shared Lives Plus