Strengths-based practice: social care’s latest Elixir or the next false dawn?

Abstract

There has never been such a consensus that social care is in crisis in England. However, it cannot be assumed this will result in fundamental rethinking of the future. Social care continues to search for a miracle cure that will painlessly transform it into a system both personalised and will cost less. The current ‘elixir’ is ‘strengths based practice’. This article suggests, however, that the current depersonalising and wasteful practices which strengths based practice is meant to replace are a product of the system within which practitioners work. There is unlikely to be significant change until that system has changed. If the current sense of crisis translates only into short-term action to keep the system afloat, the elixir will most likely be the prelude to the next false dawn.

Keywords:

• Strengths-based practice
• personalisation
• personal budgets
• person-centred practice

Context

There is currently a major and widely held sense of crisis in social care. Sector leaders talk about it being at a ‘tipping point’ (Care Quality Commission, 2016) with calls for a ‘social movement for social care’ (Association of Directors of Adult Social Services, 2016). The crisis stems primarily from concern about reduced funding levels and the ability of social care to deliver what is expected of it in relation to reducing demand on acute health services. Insofar as that is the case, any action flowing from such concerns are likely to do no more than keep the current system afloat. This will not address the more deeply held and on-going concern within the sector and amongst the people who use it that it is a system that continues to be both disempowering and wasteful.

We have previously set out evidence (Slasberg and Beresford 2016a) that the belief in England that up-front allocations of money were delivering the promise of a ‘personalised system which is on the side of the people needing services and their carers’ (HM Government 2008, 2) is working is misplaced. In a tacit acknowledgement of the reality of this conclusion, the sector now seems to be embarking on another ‘new’ approach. Strengths-based practice is now seen by sector leaders as the way forward. Think Local Act Personal (TLAP), the body created to lead the government’s personalisation agenda, has published relevant guidance (TLAP 2016). In a foreword, the Chief Social Worker at the Department of Health sees it as of ‘vital importance’ to ‘transform social care’ (2016, 2). The Guardian (2016) published a feature on the new practice describing it as ‘radically different’.

TLAP describes strengths-based practice as practice that:

Promotes the skills, abilities and knowledge of the person with care and support needs and their carers

Promotes individual wellbeing by encouraging independence, self-care … before specific service solutions are sourced. (2016, 5)

It will be brought about by the ‘development of an adult social care workforce’ that ceases to deliver the ‘institutional machine’ (2016, 9) created by traditional assessment and care management.

Proponents of personal budgets caught attention with claims of dramatic cost reductions, as high as 45% (Leadbeater 2008). Proponents of strengths-based practice are replicating this approach.

The claims being made for strengths-based working

Calderdale, Shropshire and Essex are amongst the councils leading the way.

Calderdale

Calderdale’s ‘Gateway to Care’ service is a ‘front end’ staffed by qualified social workers and nurses whose practice with people would ‘focus on what they can do for themselves either independently or with family and community support’ and ‘building on people’s strengths’ (Local Government Association [LGA] 2014, annex, 5).

Calderdale made the claim that by 2013/14 ‘only 3% of people who contacted the council needed to have a full social work assessment’ (TLAP 2016, 32). In order to appreciate the scale of this claim, nationally 27% of contacts in 2013/14 resulted in an assessment (NASCIS 2016). Calderdale predicted their spending would fall from £72.94 million in 2013/14 to £68.63 million in 2014/15, a reduction of 6% (LGA 2014, annex, 5).

The formal annual activity returns made by Calderdale tell a different story. The number receiving a social care assessment actually increased from 1215 in 2012/13 to 1575 in 2013/14 (NASCIS 2016). The numbers of those who went on to receive a service following their assessment also increased, from 985 to 1225. What did change dramatically, however, was the number of people Calderdale reported as having contacted them. This more than doubled from 6875 in 2012/13 to 14,790 in 2013/14. This is less than the 37,000 referrals Calderdale informed the LGA they had in 2013/14 (LGA 2014, 14) and which would be the scale of contacts required to justify their 3% claim. It would appear that the eye-catching reduction in the percentage of people needing continuing support owes more to an increase in the numbers of contacts being counted than any reduction in the numbers of people needing continuing support.

The financial data reinforce this view. Spending in 2014/15 did not decrease but actually increased by 4.5% to £76.1 million.

Shropshire

Shropshire has also focused on putting qualified staff at the ‘front end’, outsourcing the work to a social enterprise called People2People. The service started in 2012. Its task is ‘supporting and enabling people to build their personal and social resilience, maximising relationships and wellbeing before supplying state services to meet needs’ and has led to ‘significant reductions in spend for adult social care’ (TLAP 2016, 20).

These claims are not borne out by the audited financial returns. Shropshire’s spend in the three years between 2012 and 2015 was £102 .7 million, £102.5 million and £102.4 million in the respective years, mirroring the national trend (NASCIS, 2016).

Essex

Essex has adopted the ‘three conversations’ approach (The Guardian 2016). In the 18 months of operation, Essex claims a near halving of the percentage of people referred who have gone on to require continuing support, from 11% to 6.5%. However, at the same time they calculate the savings to be £2 million per year. Given that spending in Essex is over £500 million, this represents a mere 0.3% reduction, nowhere near the equivalent expected reduction in support.

Why is there such discrepancy between claim and reality?

All of the trailblazing councils identify the need to replace traditional assessment and care management. They describe traditional assessment and care management in various ways: it makes practice ‘system and service driven’ (TLAP 2016, 27); ‘a bureaucracy aimed at rationing resources’ (2016, 11); a system with an ‘emphasis on process rather than people’ (2016, 12); social workers need to be ‘freed from the shackles of care management’ (2016, 13); a system leading to ‘premature intervention and over-provision (2016, 20); and a system of ‘minimising risks and creating ‘safe care’ for professionals and service providers’ (2016, 27).

However, none of these descriptions offers an explanation for why this style of practice came into being and has remained so dominant. The suggestion that change can come about simply by developing the workforce makes the implicit assumption that councils and their workforces have opted to work in this way and can opt to work differently. This, however, begs the following question: why have councils opted to employ a system that is so dysfunctional and so antithetical to the stated values and skills base of the dominant professional group, and why have practitioners been so compliant in delivering it?

The absence of answers to this question suggests something fundamental, but unacknowledged, exerting its influence.

The problem at the heart of the system

We have previously identified the way the eligibility question is addressed as the core source of a depersonalising system (Slasberg and Beresford 2016b). Anxiety about potential cost has led to the creation of a system that results in ‘need’ being defined by the available resource. This circular definition of ‘need’ means political and sector leaders have no information about any gap between needs and resources. Thus the Kings Fund and Nuffield Trust (2016) found that, despite recent cuts, councils had no knowledge of unmet need and remained confident that all ‘eligible’ needs were still being met. Current claims by sector leaders of funding shortfalls are entirely reactive – to recent funding cuts, price squeezes, demographic change and recent pressures created on the NHS. The absence of reference to chronic problems allows the perception that the baseline funding level is correct.

The circular definition of need has a profound impact on practice. Councils deliver it through what has been called ‘a street level bureaucracy’ (Henwood and Hudson 2008, 122). Practice is highly localised, defining in an opaque way the categories of ‘needs’ that will be met. The function of practice is to fit the person into those categories. Practitioners thus become conditioned to their role, despite their training and in the face of their values.

Neither TLAP nor the trailblazer councils make any reference to the eligibility question. The implicit assumption is that if reductions in spend of the scale they promise are achieved, the problem will disappear.

How might exaggerated claims arise?

It is relatively straightforward to work in strengths-based ways with people who do not yet require public resources. The practitioner can focus on the person, their views of their needs and the strengths and assets around them without having to also deliver the eligibility process. The situation changes if the person does require public resources on a continuing basis – the eligibility-based process becomes dominant. Basing projections on work with people who do not require such resources should not be assumed to be representative of those that do.

What needs to happen?

The move to put practice at the heart of a transformed service is to be welcomed. TLAP’s description of strengths-based practice is consistent with previous descriptions of person-centred practice seen as the key route to personalisation (Beresford et al. 2011). The uniqueness of the needs of individuals, the complexity of thought to understand each person’s needs and the best approach to meeting them requires the practitioner to work in intimate partnership with the person.

However, the eligibility question will not disappear. A new answer is required if the policy environment within which such practice is possible is to be created. The circular approach to ‘need’ has to be replaced; the taboo about unmet need will have to be lifted. We have set out how this can be achieved in terms of the law, policy and practice (Slasberg and Beresford 2014, 2015).

There is a considerable irony in the situation. The system which denies the existence of a funding shortfall is itself a significant cause of the shortfall. Allocating resource to pre-defined categories of ‘need’ makes a poor match of resource to actual need. TLAP (2016) reported councils observing how the current system creates dependency, with one saying it has the effect of ‘sucking in’ service users (2016, 5). Bolton draws attention to evidence that supports this view:

In the last decade evidence has further emerged that a little bit of help may be bad for the person. When a person stops carrying out tasks that they could previously undertake with some difficulty they are likely to experience some deterioration in their condition. The study undertaken by the Commission for Social Care Inspection on the use and application of eligibility criteria by councils found that those councils with the more generous thresholds of eligibility also had the highest admissions to residential care. (2016, 15)

The circular definition of need means there can be no information upon which to know how much of the £14 billion spent on social care nationally is mis-spent in this way. At the same time there is compelling evidence from organisations that represent service users and carers for large volumes of authentic needs not being met now and in the past.

The true cost of meeting all authentic social care needs cannot be known until all inappropriate spending is stopped, and all authentic needs are acknowledged. Neither can happen without a new answer to the eligibility question.

Conclusion

Good practice must be at the heart of a system that personalises, empowers and makes best use of public money. However, good practice cannot change the system. The system must first change. Unless that happens, social care is on course for its next false dawn.

Disclosure statement

No potential conflict of interest was reported by the authors.