SOCIAL SERVICES RESEARCH
GROUP, SCOTLAND
THE IMPACT OF ELIGIBILITY CRITERIA
ON PREVENTION
Colin Slasberg, October 2013
LEVELS OF PREVENTION (ADSW, 2010)
Primary
Aimed at people who have little or no particular
social care needs or symptoms of illness. The focus
is therefore on maintaining independence and
good health and promoting wellbeing
Non assessed services and
community development
Secondary
Targeted services
Aims to identify people at risk and to halt or slow
down any deterioration, and actively seek to
improve their situation.
Tertiary
Aimed at minimising disability or deterioration
from established health conditions or complex
social care needs. The focus here is on maximising
people’s functioning and independence
Continuing support;
• which needs are met
• how they are met
THE IMPORTANCE OF TERTIARY PREVENTION
Leicestershire seen as the leading exemplar of secondary prevention through reablement. CSIP reported that staff were concerned how their good work was
undermined when people returned to on-going support. Their concern is supported
by the following evidence
Between 200 and 2008, England
increased provision of home care
by 46.2% and Leicestershire 54.2%.
Over the same period, the number
of permanent residents nationally
fell by 10.9%, but only by 3.8% in
Leicestershire.
NICE stake holder report re standards in home
care, 2013
“There was wide agreement across the groups that it was
imperative for it reablement to be included but broad consensus
- and strong feeling - that reablement and homecare cannot be
distinguished from one another, i.e. that reablement ought to be
considered as an outcome and philosophy that should underpin
all aspects and stages of homecare”
ELIGIBILITY CRITERIA AND TERTIARY PREVENTION
• There are two distinct issues that diminish tertiary prevention;
1. Insufficient resource, with priority inevitably given to
burning fires
2. The way the scarce resource is allocated – the rationing
process
• Change should begin with the second for the following reasons;
• It is within grasp, as it does not require more resources
• A reformed rationing process can create a more sure path
toward a better political settlement for social care
INSUFFICIENT RESOURCE
• A service based view is not sound, that lower level services have a
preventive impact is not sound. John Bolton draws attention to two
studies that disprove the assumption that low level services have
preventive value;
Canadian study
Seniors receiving preventive home care were about 120 per cent
more likely to lose their independence than seniors not receiving
preventive home care
PSSRU study
Councils whose FACS threshold was moderate or low had higher
levels of state funded admissions to residential care than those
that had critical or substantial criteria (Forder, 2007)
• However, it may be reasonable to believe a needs based view is sound,
and that people whose dignity, sense of self worth and self fulfilment are
low are less likely to maintain motivation
THE RATIONING PROCESS
CSCI said the following of England’s system of resource rationing
– ‘FACS’ – in 2008;
• Leads to unduly standardised assessments
• FACS was an attempt to move away from a service–led
approach to support, ie where people are fitted into
available services, but evidence confirms earlier findings of
the continuing influence of such a model
• the FACS framework encourages a focus on what cannot be
done by individuals (a deficit model) rather than on what
they could do with support and what outcomes people
want to achieve
• The system does not help us deal with the needs of people
below the eligibility threshold, yet this is preventative
services territory (ADASS)
ANALYSING THE REASONS
• Assessments serve the resource rationing process, which is the priority
concern of service users and council. The resource rationing process
thus becomes the dominant driver in shaping how assessments are
carried out.
• FACS is based on a flawed concept;
• The variability of individual need and the costing of meeting them
makes notion of being able to band needs and predict the cost of
meeting each band is undeliverable.
• This is mitigated at the operational level by the assessment
delivering the resource rationing process supposed to be delivered
strategically. This is made possible by high levels of elasticity in how
the bands are interpreted. This results in an appearance of equity
whilst concealing major inequity, both between councils and
between user groups as historically set budgets determine eligibility.
DAMAGE TO THE ASSESSMENT PROCESS
•
•
•
•
The scope of the assessment is narrowed to
affordable needs, with fear of declaring any other
needs ‘eligible’. Panels police the assessors and
further reduce assessments where they feel able to
Weight of dependency is the most persuasive
currency. This encourages the deficit model
Needs expressed as services are most easily costed
Outcomes are not relevant to the decision
WHAT NEEDS TO BE DIFFERENT
Six requirements of an eligibility framework
•
•
•
•
•
•
•
Enables spend to be matched to budget
A robust approach to prioritising needs to enable consistency
without compromising the uniqueness of each person
An accessible approach to prioritising needs to enable real user
engagement
Enables needs at all levels of priority a chance of being funded
Enables a true measure of equity
Generates information about the actual cost of delivering the
vision of a care and support system that enables independence
and well-being for all
Creates a progressive assessment process
HOW CAN THIS BE ACHIEVED
Two key innovations to deliver the requirement:
1. Prioritise personal needs in the here and now by reference to
the universal human needs, eg
•
Survival
•
Safe and well
•
Self worth
•
Self fulfilment
2. Distinguish eligibility and affordability and thus separate the
process of assessment and the process of resource allocation
THE PROCESS OF ASSESSMENT
STRATEGIC
OUTCOME
PEOPLE HAVE THE SAME FREEDOM, CHOICE, DIGNITY AND
CONTROL AS OTHER CITIZENS AT HOME, AT WORK, AND
IN THE COMMUNITY
Increasing immediate priority
THE ASSESSMENT
PERSONAL
NEEDS
THE PROCESS OF RESOURCE ALLOCATION
Council/user
group one
Council/user
group two
Key
Needs met
Survival
DUTY
Needs not met
•
Equity is measured by
the proportion of
eligible needs met at
the discretionary
levels. This also
exposes unmet need.
•
Once duty is met,
budget holders can
take into account
immediate priority
AND preventive
capability armed with
outcome based
assessments
Keeping safe
Needs
eligible for
public
funding
Self worth
DISCRETION
Self fulfilment
Needs not
eligible for
public
funding
Needs that would enable a level of independence and well
being above what would be expected by most people
Needs that would fall to be eligible but it is appropriate
and reasonable for the person or those around them to
meet
IMPACT ON TERTIARY PREVENTION
• Needs in relation to continuing support that identify
outcomes are the essential first step in flexible and
responsive provision, commissioned to deliver
outcomes
• Needs that are about quality of life are recognised for
what they are, have preventive potential, and have a
chance of being funded in the short term
• Anticipatory needs can be identified with a chance of
being funded
• Unmet need is exposed and costed, with potential
impact on political processes and improved longer
term funding settlements
THE CHALLENGES
• There will be two key challenges;
• Developing the professional skill base. Assessments will
need to be capable of identifying personal needs
accurately. This has to replace the prevailing culture of
standardising and objectifying needs
• Political integrity. The system needs to be willing to
acknowledge the funding gap and need to reduce it, albeit
over time. This has to replace the prevailing culture of
denial, supported by professional practices that repress
information about unmet need.