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This essay will look at the ethical considerations present for a social manager faced with budgeting decisions. This essay will consider evidence on social care management priorities and ethics as well as any available guidance on budgetary decision-making in order to complete the assignment. Theoretical perspectives on social care priorities will be examined to see if these provide any additional insight into making difficult decisions about priorities of care. The practice context will be considered in order to see if there may be other previously ignored factors at work here.
The case study is about a social care manager who is faced with having to reduce their service’s spending. Budgeting options may include the rationing of care, the priority of preventative services, the assessment of needs to determine resource allocation and other possibilities. The manager must take ethical considerations into account when making their decision as well as theoretical perspectives and practical realities.
A consideration of ethical factors is a wide-ranging remit including the consideration of all factors that have some moral bearing on the situation. In the case of social care, this is likely to be almost any aspect of the services as much of the service’s activities affect the wellbeing of vulnerable people: this is the reason for the services in the first place. Anything that does not have a direct impact on service users is likely to affect the work conditions of staff or the economic cost of the service to the taxpayer. So ethical considerations in this context are really the moral factors to consider in any change of social care services.
When looking at changes to budgets and cutting, the social care manager is relatively limited in the scope of what they may be able to do. Guidelines about which groups can be considered to be the most vulnerable and about priorities and responsibilities for services are centrally devised. Basic standards are set and money provided in the expectation that certain provisions will be made. In order to avoid ‘postcode lotteries’, the government makes quite a lot of aspects of care services centrally proscribed. However, there are within this many aspects of local decision-making such as the categorisation of care needs, which is one way local authorities may adjust their definitions in order to manage their costs. The day-to-day running of services and the potential for efficiencies in this area is also in the hands of the local authority, as is the pooling of resources with other services and the training and support of staff.
Much of what the social care manager will have to do in order tackle budgetary changes is an assessment of the priorities of their local service and an analysis of how the current reality of service meets these priorities. It is considered to be common sense that when resources are scarce (money, time or physical and organisational resources) then they should be used in order to do as much good as possible (Williams, 1998). This is the ages old motto of housekeeping and the modus operandi of many public services in times of lean.
Before making decisions about budget changes, the social care manager must make an assessment of the service’s priorities, which will include the health and wellbeing of services users. Yet it is appropriate to question whether the social care manager has the moral authority to make decisions about the best interests of service users and the right to decide what is in the best interests of other people (Seedhouse, 1989). They are likely to assume that health is a good thing and that the promotion of health is also a good thing. However, even such a basic concept as this cannot be assumed in the case of other individuals who may have competing rationales. For example, this becomes a particularly difficult question when working with older people, who may for example prefer to retain their independence at a lower level of health than experience higher levels of physical health but lose the ability to care for themselves in their own home.
Rationing is an emotive term, and describes the inability to give all things to all people all the time and so the need for decision-making about where to focus resources. Most often in social care services, rationing comes about as a consequence of a financial limitation, but there may also be rationing as a result of staff shortages or a lack of other resource such as cars for home visits. Rationing may often be described as “priority setting”, “resource allocation” or other similar euphemisms, particularly by those who seek to limit the blow of its reality (New, 1996).
Many of the decisions that a manager needs to take can be considered ethical decisions. Improving efficiency can be seen as an ethical decision taken in the interests of the society as a whole, applying service objectives universally and fairly can be seen as an ethically justified decision, and a consideration of the relative benefits of different groups from services is an ethically justifiable process as long as it is undertaken to ensure the most ethical distribution of resources (New, 1996).
Many managers would adopt management theoretical techniques to enable them to develop an overview of the context in which their decisions must be made and to better prepare them for reporting and justifying their budget decisions. Theoretical perspectives can enable a more objective view of the context and the tools to make cooler and more balanced assessment of the decision to be made. Examples of frameworks include a SWOT analysis of the service’s strengths, weaknesses, opportunities and threats that allows a strategy for improvements or changes to be developed (Gill, 2006). A SWOT assessment may help the manager in their assessment of how to balance budget changes with the maintenance or even the improvement of standards. Identification of the strengths and weaknesses of a service may allow a focus to be given to the thrifty improvement of weaknesses while maintaining the strengths of the social care provision.
Individuals can be seen to be under obligation to provide certain healthcare steps in order to reduce their burden on others and are morally obliged to make certain, usually public health, decisions in order to ensure their minimal use of resources. The most common example given is that of vaccination, where herd immunity for all can be obtained once individual levels of protection exceed a certain point. The obligation could also apply to the economic costs to society as a whole of poor health and so the requirement to maintain a good level of health, or to retain personal independence for as long as possible as a way of reducing dependence upon others. There may therefore be wider ethical considerations for the prioritising of certain types of care over others, particularly where difficult questions arise of which individuals have made the most effort to reduce their burden to society as a whole and whether they should be somehow rewarded (Dawson, 2007). Many would argue that it is not the place of the social care manager to make such moral judgements and that any such decisions can only be made with the backing of society as a whole through political mandate.
Priority setting is one of the most preoccupying roles of management (Dracopoulou, 1998) and this decision about priorities is usually taken with the assumption that all service users will be treated equally in terms of the assessment of their financial and care needs. It is important when a manager is setting priorities for services that this is done with the input of those whose professional responsibilities lie with the best interests of the service user. There should be no moral gulf between practitioner and manager. If there is, this implies either a misunderstanding of the objectives of the service by the manager or a failure to consider the best interests of the service user by the management. An assessment of priorities must take into account the reality that changes to the balance of costs spent on one aspect of services also imply the sacrifices that will be made by other potential service users whose needs were then either not treated, not treated for free, or not treated in the same way (Williams, 1998).
Effective decisions will often rely on the application of evidence-based knowledge in order to conclude. For example, the provision of effective treatments relies on an independent and reliable assessment of their relative efficacy in order to make cost-benefit assessments and decisions. Much of this work, particularly for the clinical aspects of care, is carried out by the National Institute for Health and Clinical Excellence (Nice) who use scientific evidence in order to make judgements about the value of a particular therapy or treatment. To a large extent, the existence of a national body such as Nice allows the problem of a postcode lottery to be overcome and assists managers in managing their scarce resources better. However, there maybe instances where the evidence is inadequate for the types of decisions being made when the manager will not have the assistance of a Nice guideline in making the best decision, such as where the process of decision-making itself may be important in terms of encouraging and developing user involvement in care, autonomy and self-sufficiency (Hunter and Marks, 2002).
There are standard measurements of priorities, particularly those related to clinical activities, which have been developed in order to assist with the kind of decision-making being indicated here. For example, QALYs (Quality Adjusted Life Years) are used in order to measure the benefits of health care against a scale of cost. These scales may seem stark to the casual observer: “For the purpose of priority setting in health care, being dead is regarded as of zero value” (Williams 1998, p21). Other, less nuanced, measures include survival rates and illness incidence rates as well as service user satisfaction measures.
Decisions such as this have been criticised as really a kind of paternalism. Some have said that health policy must always be considered from the perspectives of power as well as processes (Walt, 1994). Regarding power balances enables a proper consideration of the influence of government and other institutions over the lives of individuals and a conscious assessment of whether such power is justified in particular instances and always in the best interests of the service user.
Some have sought to tie down all the ethical factors a manager must take into account when making health or social care decisions. Seedhouse’s Ethical Grid (see fig 1) is one such example. This diagram displays the layers of ethical factors that may be taken into account. The blue layer describes the purposes of health care, the red layer looks at duties and motives, the green layer is consequences and priorities of proposed outcomes, while the black layer is the external environment and practical considerations. Such a model may be helpful to a social care manger in order to help them order priorities and ensure that all factors have been taken into consideration.
Fig 1: The Ethical Grid (Seedhouse, 1989, p209).
The subject of rationing of services is probably the most emotive part of a manager’s decision-making role and there has been and continues to be huge debate about this issue. One of the main contentions of the debate is whether care can and should be explicitly rationed, or whether decision-makers must come to the best professional decisions they can without expecting or even seeking consensus or approval at a societal level. Hunter (1997), for example, believes that even if explicit rationing delivering public and stakeholder consensus were desireable, it would not be realistic to implement because of the inevitable lack of consensus and frustration of service users are being unable to impose their view on the services they are being offered and were told they had a voice within. Many have sought to set the priorities for rationing in a clear way, but the conclusion of most is that while a system of principles may help to guide the professional, decisions can only really be made on a case-by-case basis, for whoever the care worker is making the decision: the time poor practitioner, the cash-strapped manager or the capacity-scarce administrator (Klein et al, 1996).
Many believe rationing in public sector services such as health and social care is inevitable and that the decisions of the manager are constant and integral to budget management rather than exceptional and significant in relation to cost savings (New, 1996).
In a practice context, the most important thing in an assessment of the distribution of resources and the management of costs is that the decision-maker should have a clear understanding of the objectives of the service and so the criteria relating to these objectives (New, 1996). Many see it as a relatively easy task for the well informed public sector manger to ration the service they provide, because of the close central control operated by government and the routine focus on a multitude of factors aside from profits. These decisions and the implementation of them are a different matter when the inputs of private sector organisations must also be taken into account and the demands of customers satisfied or risk loss of loyalty (Payne, 2000).
In a practice context, there are ways in which money can be prioritised in order to have least impact on services for users. For example, the reduction of waste is the first, most efficient, effective and least painful step towards working within a budget set centrally rather than according to profit margins (Dracopoulou, 1998). Waste reduction would be for example the cessation of a treatment that is not effective. In practice, however, there are unlikely to be enough areas of waste reduction to be made in order to cover a significant budget shortfall, and inevitably the manager will have to look at service reductions, which are in practice usually closely related to management priorities. These priorities may include preventative working, personalisation and multi-professional working.
Preventative working, which may include practices such as the support of older people to enable them to continue living in their own home, are an important aspect of managing care budgets in the longer term. The effective addressing of preventative working such as support for independent living requires a multi-disciplinary approach with the same goal in its sights (Dawson and Verweij, 2007). Multi-disciplinary working may in itself also save money and there have been suggestions that the poling of budgets between services, such as the NHS and social care agencies, can help to release savings and ensure better coordination of care (DH, 1998).
Previous research has found that some counter-intuitive methods of practice can be the most beneficial for patients, such as teaching them coping skills, health education and stress management upon diagnosis which has been seen to lower the incidences of depression, fatigue and confusion in cancer patients as well as to increase the vigour of the individuals and may even have an impact on their demonstrable health and survival (Buckley, 2002). New research such as this must be welcome to the social care manager attempting to balance improvements in care quality with reductions in cost.
Personalisation of care and the focus on the individual which is now such an important part of the working of care services (DH, 2006) may become more of a challenge when looking at budget restrictions and wanting to be fair. Health care practice encompasses ideas of the empowerment of individuals to control their own destiny, as a healthy life may include all kinds of medically sub-standard conditions, such as ageing and death (Illich, 1975). The important thing is how the individual adapts to changing environments and not how ‘healthy’ they are objectively assessed to be. This awareness that health and wellbeing may not be the same for all individuals and that many individuals want to have control over the priority setting of their own health care has been a huge cultural change that is still ongoing in health and social care services. The Department of Health has said that the providers of services are now less important in the consideration of care than the user, and that the quality of services from a user’s perspective and the levels of independence that they are able to maintain should be a primary indicator of the success of caring services (DH, 1998).
If it becomes impossible for the social care manager to reduce spending in a way that does not seriously impact on the welfare of individuals or on the equity of services, there may be other factors they can consider in order to manage budgets. The most likely but perhaps least palatable of these is a reassessment of the sources of funding for services. By taking a look at the potential opportunities for changing the balance of contributions made by service users at various levels of need and wealth, the manager may be able to demand more contributions and so better balance their budgets (Care Quality Commission, 2010; Bryans, 2005). There are minimum standards set, such as the level of free care set at an asset level of around £23,000 or less, but most other rationing decisions are left to the discretion of the local authority provider.
In the field of social care, ethical decisions must influence all management decisions. In our specific example of the need to reduce service spending, it has been seen that almost any decision made in this regard could be observed to be a value judgement or a moral or morally condemnable decision.
Budgets are a constant battle for health care managers, even when cuts are not being demanded. This is because there are constantly rising levels of expectation and significant increases in the user population, eg because of changing societal demographics (Bryans, 2005). Decisions on the rationing of care, changes to focus on preventative methods and alterations to patterns of contributions from service users are very unlikely to reach unanimity, both among society and even among different professionals. This reality should be known and accepted, and the decision-maker therefore empowered to make whichever fully informed decision they believe to be best (New, 1996).
While lists of service priorities are a useful tool for social care managers, the most beneficial next step for research is likely to be a better assessment of the cost-efficacy of personalised services and the best ways to approach the delivery of messages about preventative behaviours and the moral burden upon each individual to carry them out.
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