After a comprehensive and meticulous review, we have recently published an academic paper that looks into efficiency in the provision of social care services for older people in England It is a difficult, technical piece; here we describe what we did and present the main results.
Efficiency denotes ‘doing more with less’ but sometimes is used as a euphemism for cuts. This is not how we approached the issue. Rather, our yardstick was the quality of life of people receiving the services (that is, the users themselves). Higher quality of life equals higher efficiency. Simple.
Even if we focus on quality of life, we could think of efficiency in terms of either how to spend the least to generate a given level of quality of life or how to generate the most quality of life with the given bundle of resources available. We chose the latter approach. Focusing on spending the least would distract efforts away from people in need towards objectives expressed in expenditure items, sterling pounds, delivery contract clauses and the like. Instead, by focusing on making the most with what’s available we can learn about what may be behind that which matters to users of social care services and their families: their quality of life in relation with the care they get.
The NHS carries out a representative survey of the 1,064,000 people aged 65 or over receiving social care services across England and produces a national indicator of self-reported quality of life (NI 127) covering eight different domains: control, personal care, food, accommodation, personal safety, social life, occupation, and dignity. We used data for 2009/10 across 148 (out of 152) Local Authorities with Adult Social Care Responsibilities in England.
What did we find? First, that once we take into account several variables (including user’s gender and age, average experience of staff, staff-client ratio, gross expenditure per client, the mix between residence and domiciliary-based services, and proportion of services self-funded by the clients), quality of life does not vary hugely across local authorities, but there is some inequality nonetheless: the worst performing LA scores 11 per cent lower than the best.
Secondly, two variables stood out: assessment costs and eligibility criteria. Local authorities assigning a higher proportion of their budgetary resources to administrative tasks such as assessment and care management exhibit lower efficiency. It is worth noting that the Audit Commission has advocated the reduction in assessment costs for different reasons and that local authorities in future will be able to contract out assessment. Future research will assess the impact of this legal development on the quality of life of service users.
Possibly the most important finding concerns eligibility: we found that local authorities that impose more stringent eligibility criteria adversely affect the quality of life of older clients receiving their social care services. This is also worrying, very worrying.
Remember that we used data from 2010/11; since then, eligibility criteria have become more and more stringent. In 2013/14, 87 per cent of local councils with adult social care responsibilities restricted public funding to older people whose needs were classified as ‘substantial or critical’, up from 73 per cent in 2009/10. As a result, for example, the number of people benefitting from meals plummeted by 53 per cent since 2009/10 and that of clients of day care services went down by 35 per cent. It is very likely, then, that the quality of life of beneficiaries has worsened over the last three years given the negative relationship we found between eligibility stringency and efficiency, not to mention the increasing numbers who have not been getting these services as a consequence of this rationing.
Economising on quality of life. That’s bad economics!