The social care system in England does not meet the needs of the current population, and going forward it will not meet the needs of the country’s ageing population and the increasing numbers of younger people and working-age adults with life-long care needs.
A savage squeeze on funding for over a decade has meant the quality and quantity of support and care available has fallen. Those who work in the current care system have been trying to patch it up and keep it working for decades, but it is widely acknowledged that the system is now at a crisis point.
Long waits for care or even no care at all
The most obvious problem is that too many people are going without the care they need. There were an estimated 430,000 people waiting for assessment, reviews, care and support and direct payments to begin in August 2022. The time people are having to wait for an assessment has increased, with a third of people having to wait over 6 months. And even when people do get support, this support is often inadequate and their needs are not fully met.
The lack of social care capacity is causing significant and growing problems for the NHS; people admitted to hospital can not leave as they are waiting for social care support, either a place in a care home, for rehabilitation, or a home care package. This delayed discharge is reducing NHS capacity and having an adverse effect on patient outcomes.
An increasing number of requests for social care support result in no care being provided at all (27% in 2021/22 compared to 23% in 2017/18). As council funding has been cut, so they have had to ration care, by tightening the rules around who receives care, leaving many more people having to fund care themselves. Often though, despite people being eligible for care, workforce issues mean none can be provided.
It was estimated by ADASS (the Association of Directors of Adult Social Services) that between April and June 2022, 1.1 million home care hours were not delivered due to insufficient staffing capacity. There are also reports of some local authorities reducing the number of time allocated to recipients of home care services, resulting in rushed or poor care.
Workforce at crisis point as vacancies soar
The care system is nothing without staff and the current structure has for decades done little or nothing to encourage good rates of pay, training opportunities and good working conditions.
A tighter labour market in recent years due to changes to the national living wage, Brexit and changes in immigration rules, has driven up wages in other parts of the economy, such as hospitality and retail, leaving jobs in the care sector as some of the worst paid. At the same time, the sector’s ability to recruit easily from overseas has been reduced.
The result is a system that has a crisis in workforce recruitment and retention. Vacancy rates among care providers have risen sharply and there are now estimated to be 165,000 vacancies.
When providers can’t get staff they have to hand back contracts and eventually they may go out of business. This means people do not receive the care they need, when they need it. The situation is set to get worse as care requests and referrals rise.
Funding shortfall in the billions
The number of people who do not get the care they need or insufficient care is set to rise as funding will be nowhere near adequate to cover the increase in demand. The Local Government Association has forecast a £13bn annual shortfall in funding to meet rising care costs and increasing demand from an ageing population. Very few of the directors of social services are confident that they have the budget needed to meet all of their legal responsibilities.
The Health Foundation has estimated that an extra £6.1 billion per year will be needed by 2030/31 just to keep pace with the growing demand for care.
Inadequate care providers and off-shore companies
There is also an issue of where the current money paid to providers of care is going; due to widespread privatisation of social care from the 1980s onwards, local authorities are paying vast sums to private companies, who are not necessarily providing even an adequate service.
An investigation by The Guardian in 2022 found that almost half a billion pounds has been spent buying beds in the worst care homes in England in the last four years, driving profits for private investors while residents suffer unsafe treatment.
To make matters worse, a few large operators are making profits but funnel them to private equity investors overseas, whilst others are in difficult financial positions and struggling to remain financially viable. As a whole this makes for a highly unstable market, one where borrowing is high, staff pay is low and tight cost controls are in place.
“Reform and investment” needed
Whilst it is clear that more funding is needed, a report from The Fabian Society – Support Guaranteed: The roadmap to a national care service which was requested by the shadow health secretary Wes Streeting, and commissioned by the trade union Unison, published in June 2023, notes:
“pouring more money into a broken system is not the solution. Fundamental change must come with it, to properly serve everyone who needs care and support, and the carers they rely on. Without both reform and investment, we will never meet the ambition of an adult social care system that gives everyone the support, care and choice they need to thrive and live well.”
The idea of a National Care Service, first mooted 13 years ago at the tail-end of the last Labour government, is now once again being discussed as a way of reforming social care services enabling them to meet the needs of society today and into the future.
What would an NCS look like?
Whatever title is used, be it National Care Service, or some other name, what is clearly needed is a complete overhaul of the current system. This is the only way to produce a system in which everyone receives the care they need, when they need it, provided by staff that are paid adequately and trained well, given opportunities for advancement, and treated with respect.
The report from the Fabian Society notes that the creation of a National Care Service would be a ‘reset’ moment for social care. Instead of the current system of ‘sticking plaster’ solutions, with isolated public policy changes and occasional increases in funding, the creation of an NCS would be an ambitious project to position social care as a comprehensive and shared public service.
What the report also clearly says is that the NCS will not mean the absorption of social care into the NHS resulting in the dominance of a medical rather than a social model of need.
Key element is fair treatment of the workforce
The Fabian Society’s report makes 48 recommendations, with one of the key elements being a fair workforce settlement. This is the most pressing issue as without a new deal for care workers, the system will not be able to recruit and retain the staff required.
As noted in the report, an NCS should include a fair pay agreement that covers the whole adult social care workforce, including a sector minimum wage and minimum employment conditions, plus national employment terms, pay bands and minimum pension entitlements so that employees of NCS providers could achieve parity with similar roles in the NHS over time.
All social care under one umbrella NCS brand
The form of NCS proposed would bring national government, local councils and contracted care providers under one NCS ‘brand’, with independent providers receiving fair payments, but expected to operate as part of a public service with new standards on workforce, care and financial conduct.
And finally, who will fund this system?
The funding of social care has been a divisive subject for many years. The NCS includes a proposal for a universal contribution to help fund the system so everybody who needs support can receive some financial help. Options could include a weekly cash contribution from the state of £25 to £50, a percentage contribution to the cost, or a weekly charge cap.
The report was broadly welcomed by organisations within the sector, such as the National Care Forum. But criticisms have been levelled at the report for its lack of clarity on funding and on the reforms needed to protect people against high social care costs. On the latter, options have already been known about for years, such as a ‘cap’ on care costs, as suggested in the Dilnot report in 2011 and already legislated for in the Care Act, but there has been no political will to actually introduce them.
On funding, the report does not give a figure on how much this vision of an NCS will cost, but notes that reform will have to be staggered due to the current poor state of the economy.
It should be noted that Scotland has already taken steps to make changes to its social care system under National Care Service legislation introduced in June 2022. This differs from the NCS outlined in the Fabian Society report and primarily focuses on a shift in accountability for social care from local government to Scottish ministers. The Scottish legislation has been criticised for not tackling the real issues in the system.
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