The growing crisis in social care in England, and to some extent in the rest of the UK, can be seen as largely the result of government policies.
The current dysfunctional social care system itself, dating back to the 1993 separation of long-term care from the NHS where it was free at point of use, and its transfer to local government, where it has been largely privatised and subjected to means-tested charges, flows from decisions by the Thatcher government and 1988 advice from Sainsbury boss Sir Roy Griffiths.
New Labour pulled back from Royal Commission recommendations to reform this system.
And since 2010 over a decade of austerity has brought real terms cuts in social care spending and local authority budgets, widening inequalities in health and circumstances between rich and poor, and social care staffing problems exacerbated further by post-Brexit tightening of limits on immigration. Numbers of non-British staff seem certain to decrease. Staff shortages in social care have now reached a new peak of 105,000 vacant posts, leading some care homes to close their doors to NHS patients who should be discharged from hospital beds.
In September health secretary Sajid Javid announced an extra £478m would be allocated to fund “discharge to assess” schemes in England for another six months – money which is now being described as support for social care. But the big announcement of £36 billion to be raised for the NHS and social care over the next three years from increase National Insurance payments included just £5.4bn (£1.8bn per year) for social care, beginning next April, and running up to 2024.
The National Audit Office warned earlier this year that the total cost of care is projected to rise by 90% for adults aged 18 to 64, and 106% for adults aged 65 and over was due to double in 20 years from £28bn to £55bn per year.
The NAO report also noted that local authority spending on care reached its highest ever cash level in 2019-20, at £16.5bn, but this was 4% lower in real terms than in 2010-11. Since 2015-16, the number of adults aged 65 and over receiving long-term support arranged by local authorities has fallen, and almost a quarter (24%) have unmet care needs.
And of course ‘Baldrick’ Johnson’s infamous 2019 claim to have a cunning plan ready to sort out social care has proved time and again to be as worthless as his promise of an “oven-ready” Brexit.
But while many of the problems of social care have been inflicted by ministers, new studies of social care systems in the EU remind us that many EU governments facing similar problems have found different ways and chosen different priorities.
Both reports focus on long term care of the elderly, whereas we know that in England social care is viewed more widely: ‘adult social care’ covers social work, personal care and practical support for adults with a physical disability, a learning disability, or physical or mental illness, as well as support for their carers. Roughly a third of adults receiving social care in England are aged 18-64, two thirds are older, and the EU’s Social Protection Committee points out that “the great majority of the recipients of long-term care are older people.”
The European Social Network (ESN) study Putting Quality First, Contracting for Long term Care begins with the differences between the systems in the 27 EU countries, noting that public expenditure on Long Term Care (LTC) ranges from “small budget lines within social assistance schemes, as in many Eastern European countries” to spending of over 3% of GDP in the Netherlands or Sweden. Current UK spending (£28bn) is around 1.3% of GDP.
But there are also big variations in the extent to which services and facilities are delivered by public, private not-for-profit or for-profit providers: “While in the UK and Germany the share of private providers is comparatively high, the Nordic countries are still characterised by extended public service provision.”
The British government of course has never respected, and now broken from the European Pillar of Social Rights, Principle 18 of which states: “everyone has the right to affordable long-term care services of good quality, in particular homecare and community-based services.”
And while few in Britain would even have been aware that this commitment existed, England can be found to be drifting further away from the mainstream acceptance in most of the rest of Europe that the need to support older people is more important than guaranteeing the profits of private care home bosses and domiciliary care companies.
Some systems are much more proactive than others in supporting informal carers: Sweden, Germany and Austria in particular have invested in specific services to support informal carers, Spain pays them an allowance and contributes to their pensions: Finland and Slovenia offer informal carers training courses.
By contrast few steps have been taken to implement promises in England of more support for carers.
However the British drive towards privatisation, competitive tendering and marketisation of social care has become the norm even in systems that are much more generous than in England. The ESN report notes:
“With the dissemination of New Public Management principles [purchaser/provider split, compulsory competitive tendering, contracting and performance management] … over the past three decades, practices of procurement, commissioning, purchasing and contracting have entered public service provision and governance in Europe, though with rather different meanings, scope and impact.”
The common assumption, as in Britain was that competition would both increase efficiency and reduce prices: but price competition can lead to a race to the bottom in quality of care, especially if there is not strict monitoring of contracts and precise specification of services. Nonetheless:
“Over recent decades, most countries in Europe have seen an increase of private provision and promoted access to new (private) providers due to explicit national policies that introduced New Public Management approaches and compliance with EU market rules. Purchaser-provider splits, compulsory competitive tendering and abandoning of traditional subsidised funding led to the establishment of ‘long-term care markets’.”
The focus of the ESN study is not to challenge these new markets, but on trying to improve quality within them. It notes that contracting individual services “is not sufficient to ensure seamless LTC”. While in theory public authorities could seek to commission and coordinate the services of several providers, “we do not yet have examples of such practice.”
Instead ESN suggests a different, more complex approach, already in use in the Netherlands:
“rather than paying for or reimbursing individual services (based on the number of places/beds/clients, or by the number of hours or days), integrated LTC delivery could also be purchased as a ‘bundle of services’ based on defined outcome(s), such as reduced hospital admissions …”
The study also looks at, but appears unconvinced by personal budgets for individuals to buy their own social care, noting from the outset that they are linked to needs assessments “to work out the type of care and support the person needs, how much it would cost, and how much they may be able to afford themselves.”
The ESN does acknowledge that EU law allows governments to exclude as much of social care as they wish from procurement law, allowing them to retain it with the public sector: but it also notes and does not challenge the fact that “a fundamental aim of the EU is to create a common market based on competition, equal treatment and transparency …”
So the main focus is on seeking ways to best regulate and manage the private sector to increase quality. One obvious problem is that competitive markets are themselves unstable: larger companies tend to deal with smaller ones by taking them over or forcing them out of business. In Finland for example:
“In long-term care, there has been a huge increase of private for-profit provision during the last 15 years. At the same time, the number of private companies as providers has decreased dramatically. Instead, three to four large companies have taken over most of the market (…).”
The largest share of private providers is in Ireland and the UK, while in residential care the share of private for-profit companies ranged from 1% in Croatia to 80% in Ireland. The average in LTC as a whole is a market share of 42% for the public sector, 36% for-profit and 22% non-profit.
But the reliance on a competitive market has its on-costs, with respondents to an ESN questionnaire flagging up their greatest concerns as bureaucracy in tendering (63%); quality of care (59%); rising prices (44%); and continuity of provision (30%). Among the challenges in procurement from the market the ESN notes a problem that is now increasingly obvious in England:
“Procurement processes also lead to unsustainably low prices, which have detrimental effects on terms and conditions for staff and ultimately lead to workforce shortages, which limit supply.”
It also notes “Tenders do not always guarantee the choice of the best organisation in terms of reliability and ethical principles.” Furthermore: “it has become evident that strategies of pure cost reduction resulted in unsustainable conditions of service provision.”
A second report, The 2021 Long-Term Care Report: Trends, challenges and opportunities in an ageing society, commissioned from consultants KPMG by the EU aims to “increase understanding of long-term care supply structures in member states”.
It also points to the increase over 30 years in market-based and private provision and that among the common features across the EU has been a growing focus on home care and services to support people living at home, and the fact that while policies are shaped nationally, control of social care tends to be local. Most long-term care providers are also based in the country itself, while the few multinational providers are mostly for-profit corporations.
The KPMG report analyses four main trends in reforms in social care: measures to improve the situation of informal carers (in 15/27 EU states, most notably in Poland, Austria, Czech Republic and Germany which have introduced or increased cash payments); improving access to and affordability of home care (in 16/27 EU states); improving access, affordability and quality of residential care (in 18/27 EU states); and improving the situation of the professional long-term care workforce with increased salaries, improved training and working conditions (10/27).
A summary of recent reforms (from page 104) goes on to look at steps to coordinate or integrate health care and social care, noting a major reform in Bulgaria, the 2018 decision in Greece to establish 150 ‘integrated care centres for older people,’ and projects in Belgium and the Netherlands.
Reforms to improve quality of care have been implemented in Bulgaria and Finland, and the Netherlands has invested in “ambitious plans for improving the quality of residential care,” with large-scale government investment.
Measures to improve the recruitment of social care staff include steps and spending to make care jobs more attractive in Sweden, Netherlands, Germany and Croatia. Salaries and conditions have been improved in Germany, Czech Republic and Netherlands, while Sweden has focused more on training and upskilling.
However KPMG notes there have been no reforms in the majority of members states with shortages of care professionals. The report would obviously have included the UK in this bracket had Brexit not occurred.
Measures that have been taken to support informal carers include a tightly regulated new carers’ allowance in Portugal, paid leave for people taking time out from work to care for relatives (France, Slovakia, Czech Republic, Austria) and training (Bulgaria, Ireland, Finland).
KPMG’s round-up points to more reforms for the sector that are coming, notably in France, Austria, Estonia and Slovakia, while Finland is also planning new ‘health and social services centres.’
So while PM Johnson and his ministers dither and debate on how to address the social care conundrum, and face a service that has been dislocated, fragmented and privatised for over 20 years by ill-conceived market reforms, governments in other countries are already grasping the nettle and taking action in hopes of attracting the workforce they will need.
It’s not hard to guess what the more attractive prospect might be for care workers: when there are countries that have improved pay, conditions and training – and are easily accessible through the EU’s freedom of movement – why would they look to the UK where none of these is true, and things are getting visibly worse?
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