When it comes to the interpretation of needs, Tanner (2003) discusses that people want help not care yet it is becoming increasingly common for social services to take over duties where previously health care was concerned, meaning that there is little time left for workers to address the social aspect of the needs of the clients such as help with household duties (Netten, 2005). As a result of this, people are increasingly resorting to purchasing their own services to meet their needs or relying on informal carers (Bernard & Philips, 2000). This creates significant inequality in the provision of services as those who can afford it can have access to a better quality and choice of services whilst those who cannot afford this are left with whatever services are available in their area and that’s if they manage to fit the criteria. Even if they have to money to pay themselves, many older people feel disappointed by this as having paid their taxes and national services all their lives, have been let down by the government and have to pay themselves if they are to have their needs met (Glendinning, 2002).
The ‘Fair Access to Care Services’ (DH, 2002) is a policy attempt to increase the equality of access to services and seems at face value to be a huge step forward. It places the spotlight on well being, independence and preventative measures to enable people to remain in their own home for as long as possible as well as being positive in the acknowledgement of the need to follow a more social rather than medical model of care (Tanner, 2003). The ‘Fair Access to Care Services’ (DH, 2002a) aims to focus on the risks to independence if help is not provided, depicting 4 categories from critical to low risk (Newton & Browne, 2008). The problem with this when it came to implementing the strategy is that to do so, councils had to set the boundaries for each category and then estimate the costs taking into account their resources. This contradicts the goals of the National Service Framework which aims to reduce the variation of services nationally as it still allows each local authority to set the boundaries (allowing variation) as opposed to having a national standard (Newton & Browne, 2008). This in turn can have an effect on who receives services and often resources do not cover lower level needs as they are taken up by the more critical, resulting in some needs not being met.
Worth (2002) shows from findings in her research, that the social workers and practitioners interviewed would love nothing more than to be able to use their skills to arrange appropriate care packages for older people but due to resources still driving the assessment process, it leads to them not even ask certain questions as they know they will not be able to meet certain needs. This point highlights why there are cases of unmet needs as certain aspects of peoples care are not even discussed if it is known that a resource is not available. Such factors around resources emphasise how difficult it is for an objective to raise standards to coincide with achieving value for money in a sector with such limited resources (Netten, 2005).
Alongside services provided by the state, user payments are another policy measure that can help to create equality for older people. Ungerson (2004) highlights that they allow people to gain independence and be empowered as they can control the type and timing of the care they receive. This would benefit an older person greatly as they would be the decision maker as opposed to a dependant user and decide themselves how their needs were to be met. Arksey and Kemp (2008) explain this further and discuss that by giving duties and having a contract of employment, this limits the emotional aspects found in some caring relationships. A positive for the state is that due to the nature of direct payments, it will indirectly commission labour and postpone residential care for the user which then reduces public costs and boost the economy (Daly, 2002). Glendinning et al (2008) explain that although it reduces costs in the long term by postponing the use of more expensive services, the direct cost to the state in the short term is actually increased. In their report on Individual Budgets which are similar to Direct Payments, the increase in costs is thought to be due to such personalised care which in turn can highlight unmet needs unnoticed before during traditional care focus on daily living activities. This illustrates that the use of direct payments in older people may increase equality for them by helping them to have a wider variety of aspects of their social care tailored to suit them by the use of a personal assistant. As an employer, the individuals themselves would be able to decide what their needs are as opposed to what the state deems them to need, but this is only in succession of meeting strict eligibility criteria to qualify for Direct Payments which is contradictory.
Direct payments are not without their limitations. Even though there are many positives to using them, there is still low take up and many barriers that exist. The direct payment development fund has been designed in an attempt to remove barriers to using such payments to pay for care and increase awareness (Glendinning et al, 2008). Direct Payments are characterised by workers with few qualifications and low regulation of the workers. This means that the users may not receive adequate care if the worker is not fully trained to deal with any complex needs and there safety could be severely compromised (Reed et al 2005). In addition to this the National Service Framework for Older People highlights that specialist staff should be employed to care for older people with the right skills and knowledge to meet their needs, yet the promotion of direct payments and poorly regulated standard of workers heavily contradicts this point.
Another problem for older people regarding Direct Payments is that they were originally intended for working aged disabled people (Ungerson, 2004). Glendinning et al (2008) discuss that whilst younger people may have the time and the drive to be pursing extra activities, older people tend to approach services at a time of crisis, when they are feeling vulnerable and in need of urgent help. In a time such as this, the stress of trying to employ a personal assistant and arranging all aspects of you own care could be far to difficult. In the study older people expressed anxiousness about the risks of finding their own care provider rather than a regulated service worker and also didn’t want the burden at a time of crisis of planning their own support.
Services are undergoing a drive to increase quality for the user through independence and choice but as a result of attempting to contain the costs through tight eligibility criteria, a medical model still seems to be in place as it is the most critical needs that are taking up most of the resources. Although the policy aims are to create equality and address all needs from critical to low, Local Authorities can still set the boundaries so the goals of the policy are compromised.
The focus on independence, choice and well being in the current policies are positive steps forward, but on the other hand ones that are difficult to measure. By looking at the performance indicators used, it is easy to see that there are discrepancies between what the government deem these to be in comparison to what older people envisage to mean for them. To improve this, performance could be better monitored by acknowledging current research around the meaning of independence to older people and have these areas as targets to see if the policies are making a difference.
Direct payments seem to be a much improved way of enabling individuals to be more in control of the care they receive. One barrier that stands out in particular to the use of direct payments is the notion that older people approach services at a time of crisis therefore arranging own care can be a hindrance. If the employment of personal assistants to care for people was to be better regulated and less complicated this could ease the strain. In addition to this there is a huge contradiction in one of the goals of the National Service Framework for Older people, increasing the quality of carers and on the other hand attempting to increase the use of direct payments which is characterised by unqualified workers. For that to work then there would need to be better training for carers, as well as better regulation and monitoring of the employment of the workers.
Considering the measures discussed, although equality and diversity are important dimensions of the policies and indeed within the society they exist; vague targets that seem off subject make it difficult to asses their impact. There are many contradictions between cost’s, quality and emphasis which seem to make it increasingly difficult for Local Authorities to follow, especially as they can still set boundaries themselves. To move forward, increased funding and more insightful targets in the sector could help tremendously.
[Word count: 2133]
References:
Age Concern, 1990. Age, The Unrecognised Discrimination: Views to provoke a debate. Portsmouth, Grosvenor Press.
Arksey, H. and Kemp, Peter A, 2008. Dimensions of Choice: A narrative review of cash-for-care schemes, Social Policy Research Unit [online] Available at: [Accessed 17/12/2008]
Baldwin, M, 2002. New Labour and social care, continuity or change? In: Powell, M, 2002. Evaluating new labours welfare reforms. Bristol, The Policy Press.
Bernard, M, Phillips, J, 2000. The challenge of ageing in tomorrow's Britain. Ageing and Society [online] 20 Available at: [Accessed 17/12/2008]
Daly, M, 2002. Care as a Good for Social Policy. Journal of Social Policy [online] 31 (2) Available at: [Accessed 20/12/2008]
Department of Health, 1998, Modernising Social Services, London, The Stationary Office
Department of Health, 2002a, Fair Access to Care Services: Guidance on Eligibility Criteria for Adult Social Care, London, Department of Health.
Department of Health 2001a National Service Framework for Older People’ London, The Stationary Office
Glendinning, C, 2002. European policies on home care services compared In: Byetheway, B, Bacigalupo, V, Bornat, J, Johnson, J, Spurr, S, 2002. Understanding Care Welfare and Community: A Reader. Oxon, Routledge.
Glendinning, C, Challis, D, Fernández, Jacobs, S, Jones, K, Knapp, M, Manthorpe, J, Moran, N, Netten, A, Stevens, N, Wilberforce, M, 2008. Evaluation of the Individual Budgets Pilot Programme Summary Report, Social Policy Research Unit, University of York [online] Available at: [Accessed 20/12/2008]
National Statistics, 2003. Health & social care: 2.8m aged 50+ provide unpaid care [online] Available at: [Accessed 20/12/2008]
Netten, A, 2005. Personal Social Services In: Powell, M, Bauld, L, Clarke, K, 2005. Social Policy Review 17: Analysis and debate in social policy. Bristol, The Policy Press.
Newton, J, Browne, L, 2008. How Fair is Fair Access to Care? Practice: Social Work in Action [online] 20 (4) [Accessed 5/1/2009]
Reed, J, Watson, B, Cook, M, Clark, C, Cook, G, Inglis, P, 2005. Developing Specialist Practice for Older People in England: Responses to Policy Initiatives. Practice Development in Health Care [online] 4 (4) Available at: [Accessed 17/12/2008]
Tanner, D, 2003. Older people and Access to Care. Brtitish Journal of Social Work [online] 33 (4) Available at: [Accessed 17/12/2008]
Ungerson, C, 2004. Whose empowerment and independence? A cross-national perspective on ‘cash for care’ schemes. Ageing & Society [online] 24 (2) Available at: [Accessed 17/12/2008]
Walsh, M, Stephens, P, Moore, S, 2000. Social Policy & Welfare. Cheltenham, Stanley Thorn Publishers.
Weiner, K, Stewart, K, Hughes, J, Challis, D, Darton, R, 2002. Care Management Arrangements for Older People in England: Key Areas of Variation in a National Study. Ageing & Society [online] 22 (4) Available at: [Accessed 17/12/2008]
Worth, A, 2002. Health and Social Care Assessment in Action In: Byetheway, B, Bacigalupo, V, Bornat, J, Johnson, J, Spurr, S, 2002. Understanding Care Welfare and Community: A Reader. Oxon, Routledge.