The late Donald Rumsfeld was unfairly ridiculed when he tried to explain the concept of ‘known unknowns’ to a sceptical public. Yet his basic point is obvious and helpful: there are many things we’re aware of but don’t fully understand. It was a concept widely used before Rumsfeld – I once met a management consultant who referred to ‘known unknowns’ as ‘kunks’ and I have adopted the term ever since. (‘Unknown unknowns’, which we won’t get into here, were known as ‘unkunks’.)
Largely unnoticed, the Department for Health and Social Care (DHSC) published in early December its ‘Evidence Review for Adult Social Care Reform’. It deserves to be widely read, not least because it is full of ‘kunks’. Here are four particularly interesting ones:
- We don’t know how many people are eligible for state support but don’t receive it (let’s use that as our definition of ‘unmet need’). Perhaps even more importantly, we don’t know why they don’t. For example, we do not even know the exact number of people with learning disabilities in England. Yet working-age people with a learning disability are the single largest area of local authority social care expenditure and likely to be central to future care demand.
- We don’t know how many people currently fund their own care, even though that is the focus of much of the Government’s reform agenda (it’s curious that avoiding people selling their homes to pay for care is a key driver of Government policy, yet we have no idea how many currently do that). The problem is particularly acute in home care and in data on the number of under-65s who self-fund.
- We don’t have good evidence about the most promising types of technology and innovation in social care. Of course, we know some things that would work but not which have most potential, and there is relatively little evidence about what users of adult social care most want from technology, which you might think is quite important.
- There is some evidence of the impact of health and care integration on outcomes and quality, but little about cost-effectiveness. Indeed my colleague Siva Andanaciva noted recently that there is, in fact, a general lack of clarity about what integrated care systems are intended to achieve and how it will be measured.
Though it is generally a very useful report, the DHSC document does have its weaknesses. The biggest is the failure to include evidence on the views of people with care needs. The report does note a gap in understanding of “the type of care people and families will be willing to provide for themselves and the sort of support which would be most effective for them” but fails to follow this up with a wider section summarising evidence about the views of people who do draw on services (or those who don’t but have care needs). This is not a ‘kunk’: we know quite a lot about what people want, so it is a big omission.
Still, it is 122 pages of detailed analysis on adult social care and was delivered just before Christmas. For a policy wonk, it proves there is a Santa.