Change that leads to better lives

Work as a ‘social care’ outcome (and not using fear as a weapon)

Three weeks ago, NDTi published its research findings into the cost effectiveness of employment supports for people with mental health problems and people with learning disabilities.

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They make quite sobering reading – particularly if (like me) you think that work is a socially valued activity and a key to many of the important things in life (like relationships, self-esteem and money). If you haven’t read the findings (and please do, there are short summaries of it available by clicking here. There are important headlines based around the core finding that two thirds of local authority and NHS spending is on non-evidence based services that are nearly three times as expensive as those that do achieve good outcomes for people.

Beyond those headlines, three conclusions are particularly interesting to me and also add to my ongoing bafflement about the logic and thought processes that underpin policy and service decision-making. To understand this, it is important to remember two other important facts (see our reports for the supporting evidence): (1) it costs the taxpayer less if disabled people are in work rather than not, (2) it costs local authorities less to support disabled people into real work rather than provide things like day centres.

Firstly, the research showed how cuts in commissioning capacity linked to budget reductions are costing money rather than saving it. The vast majority of commissioners did not collect the type of information from services that would enable them to take informed decisions about whether those services were providing value for money and achieving good outcomes for people. Commissioners told us this was because they did not have the time to collect it. Also, most commissioners were substantially unaware of existing evidence about what works in employment support – so did not know what data to ask for anyway.

The prime problem here is time and capacity. Commissioners who were part of the research’s action learning estimated they had, on average, ten minutes a week to focus on employment. With this, it is unrealistic to expect them to do more than participate in a basic procurement process. Ten minutes a week is insufficient to understand the evidence base, build the relationships, and understand the impact of the services they ‘commission’. As a result, the procurement process purchases non-evidence based, unnecessarily expensive, non-working services (which might nonetheless tick the meaningless boxes in the contract such as contacts achieved). More commissioning capacity would cost far less than would be saved through the resultant improved decision making.

Secondly, in many local authorities, both for commissioners and social workers, employment is still not seen as a valid social care outcome and priority. Paid work is understood as the responsibility of Job Centres (who we know lack the expertise or indeed desire to work with many disabled people), whilst social care – particularly when making financial cuts - focuses on the perceived short-term priorities of personal care and safeguarding. Too many services are still locked in the mentality of the 1948 National Assistance Act - seeing CARE as the only objective rather than helping people to have a life. (I vividly recall asking the then King’s Fund Fellow Nan Carle what would be her one line of advice to me as I started managing learning disability services in London. She said; “Remember that for many disabled people, care is a four letter word. It signifies paternalism and a lack of autonomy”.)

As a result, there is limited organisational and social work focus around supporting people to aspire to paid work, and work is not seen as a valid needs assessment outcome. Further NDTi research will be published shortly showing how this limited social work aspiration is a causal factor behind the lack of personal budgets being used to support people into paid work. The new Care Bill explicitly places supporting people into the world of paid work as a local authority wellbeing responsibility. This legislative change desperately needs to have an impact.

Finally, (and here I admit I am slightly stretching the research findings – which is why you find this point in my blog rather than the formal research report), the findings present a big challenge to the Government’s overall approach to disabled people and work. In simple terms, we estimate that if the two thirds of local authority/NHS money currently spent on non-evidence based services was spent on services that work, at least 15,000 more disabled people could be supported into paid work without spending any more money. Previous research showed that it costs the taxpayer between £3,500 and £6,500 less for a disabled person to be in work rather than be receiving full time services. Conservatively taking the lower figure, this means that using the evidence to support those 15,000 people into work would save the taxpayer over £50 million.

I would love to know the number of disabled people who have been ‘encouraged’ back into work through the Government’s current benefits-withdrawal led approach to disabled people and work and the savings to the taxpayer that have been achieved – and then do a comparison. Personally, I’ve always thought that rather than try to scare them into change, it is better to show people the benefit of doing something different and then support them to do it well.

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