Most people would agree that social care policy should be based on good, sound evidence. And most would accept that once politics and funding swim into view that is a lot easier said than done.
Former social care minister Paul Burstow can certainly testify to that. Burstow, a Liberal Democrat MP until the 2015 election, was one of the chief authors of the widely admired Care Act, which came into force earlier this year. From the time he was appointed as care minister in 2010 the act was one of his top priorities and he was keen to ensure its provisions were based on robust research as well as close consultation with those involved, including service users and carers.
For once, political differences between the two coalition partners, the Conservatives and Lib Dems, were not a big issue. Indeed, the legislation benefited from the fact social care didn’t loom large on the political agenda, says Burstow: “It managed to make its way through the government process relatively unscathed and unnoticed.”
But the elephant in the room was, inevitably, funding. “Money was always a factor and it was important to avoid creating new burdens at a time of austerity. We had to satisfy ourselves that the impact of this legislation wouldn’t necessarily load additional costs on the system,” Burstow said.
Yet funding issues now look to be threatening some of the central tenets of the act. Many local authorities are interpreting provisions such as carers’ assessments very conservatively to avoid added costs. Most critically, the government has effectively abandoned a key proposal: the £72,000 cap on care home fees.
Burstow believes by doing this the government has missed a golden opportunity not only to address an injustice but to make contact with the wider population and establish their care needs much earlier. “Unless these aspects of their needs are known to local authorities and the NHS it’s very hard to plan properly.”
The story of the Care Act underlines the complex mix of ingredients that feed into policy-making at both national and local government level.
Martin Knapp, director of the Personal Social Services Research Unit , says in his experience the Department of Health is more committed than most departments to basing decisions on sound evidence. But he still encounters initiatives where he wonders “where on earth did that come from? What is the evidence in support of that?” he says.
One familiar ploy is to make the research fit the policy rather than vice-versa. Knapp recalls having a bitter argument with a minister when his team’s report on a key initiative didn’t produce the findings the minister wanted.
Calls for cost-effectiveness also loom large. Knapp says he and his colleagues are often told: “We think it’s very good in terms of improved quality of life but what does it cost and is it worth it?’ he says. “That economic dimension is perfectly legitimate but it mustn’t trump the evidence from other sources.”
It is also true that the research base in some areas of social care is not that strong. A National Audit Office report in 2014 suggested that evidence for cost-effectiveness in social care services was much weaker than for health care. Even when drawing up the Care Act, Burstow found that evidence supporting the effectiveness of preventative programmes was “patchy” at best.
Knapp says much of telecare remains an “evidence-light” area, despite all the hype. Even health and social-care integration – while having obvious benefits – has a limited research base. “It tends to be quite localised and it isn’t always clear how generalisable these examples can be. How much does success rely on charismatic individuals and particular configurations, for example?”
Dez Holmes, director of Research in Practice, suggests that research by itself will always have limited value. Her organisation works with local authorities and the voluntary sector to foster what she calls evidence-informed practice, a triangulation approach that combines conventional research with input from practitioners and service users.
The Making Safeguarding Personal policy, based on a large body of research and fieldwork as well as extensive piloting in local authorities as part of the Care Act implementation, is an example of how this approach can improve practice, she says.
The policy aims to improve service user involvement in choices about their care. Three London boroughs – Westminster, Kensington and Chelsea and Hammersmith and Fulham – ran a whole systems pilot earlier this year and are already seeing positive results among both staff and users. It has also engendered an ongoing programme to collect feedback from users and frontline staff.
Holmes is nevertheless concerned that the growing financial pressures on local government increase the demands for quick fixes as opposed to considered, evidence-based policies.
“If social policy exists in a climate of blame, then the pressure to fix things quickly, or assume they’re broken, stops us making rational decisions,” she says. “None of us makes the best decisions when we’re under the cosh.”
She also points out that it’s a lot easier to believe in evidence-informed policies when you already agree with the evidence. “It doesn’t matter whether you’re an individual or a minister driving through a policy, you have to be aware that your values come into play.”
And it’s important to realise that when research is about human behaviour, as in social care, it can be messy and provisional in nature. “It’s not just what works, it’s what works best for who and in what circumstances. There’s a need for research literacy, not just research compliance.”
