The long-awaited White Paper on adult social care unveiled in the House of Commons this week proved to be a damp squib, little more than a 100-page ‘holding’ statement of intent or stopgap measure while the government worked on the more awkward question of health and social care integration – the latter now the focus of a follow-up paper with no release date known as yet.
The policies talked up by care minister Gillian Keegan do little more than rehash and re-present elements of the new Health and Care Bill and its ‘build back better’ plan for a “once in a generation” transformation of adult social care, the latter unveiled by the government only last week and which introduced a cap on social care costs, a mere seven years after the enabling legislation made its way onto the statute books.
And just like the care cap legislation – now heading off to the Lords for further consideration, despite the tabling of a controversial amendment in the Commons last week which undermined its vote-winning ‘halo’ potential – the adult social care paper (snappily titled ‘People at the Heart of Care’) was greeted with little enthusiasm by leading stakeholders.
The Association of Directors of Adult Social Services (ADASS), Carers UK and the National Care Forum were lukewarm in their responses, and even Jeremy Hunt, the chair of the Commons health and social care select committee, attacked the paper, calling it “three steps forward and two steps back”, and saying it would do nothing to ease pressures on hospital wards or help older people get the care they need.
So, with some providers already refusing to deliver new care packages because of staff shortages – leaving hospital managers unable to discharge patients – and with assessment waiting lists building up and home closures continuing at an alarming rate, it’s clear that far greater support for the adult social care sector is still desperately needed.
A sector in crisis
Just this week, for example, ADASS published the results of a snap survey, undertaken last month, showing that:
– almost 400,000 people are now waiting for an assessment of their needs or for service provision
– more than 1.5m hours of commissioned home care could not be provided between August and October because of a lack of staff, despite record growth in provision
– one in two councils has had to respond to a care home closure or bankruptcy over the past six months
– more than 40,000 people have been waiting longer than six months for an initial assessment
And with a record number of adult social care vacancies already documented across England – thought to be around 100,000 – the Nuffield Trust thinktank this week warned of a “deepening crisis”, as it unveiled its own research showing that the social care workforce shrank by up to 70,000 between April and October this year.
Low pay levels in social care are a major recruitment obstacle – skilled carers can earn more working in supermarkets or Amazon warehouses – but an estimated 32,000 staff may also soon leave the sector because they don’t want to be double-vaccinated. Members of the Homecare Association have warned that this government-imposed vaccine mandate will reduce their staff rosters by more than 25 per cent.
Looking ahead, adult social care charity Skills for Care has also estimated that the sector’s workforce needs to grow by 30 per cent – almost 500,000 extra jobs – to match the projected number of people reaching the age of 65 by 2035.
Funding shortfall
The government’s reluctance to invest heavily in social care long been the case. Aside from outlining details of the forthcoming National Insurance health and social care levy, which will offset the costs of the cap on care home costs, the press release for this new plan makes sparse reference to extra funding for the sector.
That’s hardly surprising, as ADASS president Stephen Chandler told attendees at the recent National Children’s and Adult Services Conference that only two per cent of the funding to be raised by the levy next year will go to pay for social care – that’s against a sector shortfall estimated by the Health Foundation charity at somewhere between £6bn and £14bn.
Equally worrying, the Department of Health & Social Care (DHSC) sales pitch for the new plan suggests local authorities will have access to sustainable funding partly through “long-term efficiencies” – normally a euphemism for cuts.
At the same time, the new plan puts councils – already financially stressed after a decade of austerity measures (spending on adult social care remained more than four per cent lower in 2018/19 than in 2009/10, despite a 17 per cent growth in the size of the population aged 80+ over the same period) – under further pressure by scrapping the system which obliges self-funders to pay more (up to 40 per cent more, according to the King’s Fund) for their care than when it is funded through local authorities.
Private care providers – more than half of elderly care home residents pay all or some of their fees, and 82 per cent of places are provided by for-profit operators, according to research company LaingBuisson – will surely resist such a move, suggesting that councils may end up having to subsidise self-funders in order to insure against further home closures.
More integration on the way?
Elements of the government’s approach to health and social care integration, largely missing from the paper presented in the Commons this week and therefore likely to emerge in the follow-up (but so far unscheduled) document, started to leak out in the days following the Commons care cap vote the previous week.
A policy paper was announced the day after the care cap vote by the DHSC calling for “ever closer working between NHS organisations and local authorities”, with the review team behind the paper scheduled to report to health secretary Sajid Javid by next March. The accompanying press release promised that a “delivery plan with clear timelines” would follow shortly afterwards.
The HSJ news site fleshed out the DHSC’s thinking the same day, floating the idea of jointly managed health and social care planning in each integrated care board area, with staff reporting both to the NHS and to local councils – a move which would require the pooling of both services’ budgets.
Later last week more details surfaced, this time directly from the health secretary, as well as from NHS England chief executive Amanda Pritchard, when they both addressed delegates at the National Children’s and Adult Services Conference. Javid outlined a proposal to create more joint roles across the health and social care sectors, while Pritchard talked of extending the joint NHS/local council ‘urgent community response team’ concept piloted earlier this year.
History lesson
But whatever appears in the follow-up paper on integration, it’s difficult not to conclude that the crisis in the adult social care sector stems largely from the creeping privatisation of health and local government services that has been part of the Tory project since the late-1970s.
Just consider this: when Margaret Thatcher swept to power in 1979 the proportion of residential and nursing care services provided by the state was 64 per cent, but by 2012 this had fallen to just 6 per cent. And the private sector provided just 5 per cent of state-funded domiciliary care services in 1993, a figure that had risen to almost 90 per cent by 2012.
This was achieved by restricting the funding available to local authorities to provide care services, forcing them to generate ‘efficiencies’ by entering into deals with the lowest-cost operators in the independent sector, in the process driving down both the quality of care. In 2013 the Centre for Health and the Public Interest (CHPI) elaborated on this approach:
“In the case of domiciliary care, local authorities were placed under a duty to demonstrate ‘best value’ in the services they provided. This meant that they were required to compare the cost of providing their own services with the cost of having them provided by the private sector, and because much the largest part of domiciliary care costs are in employing care workers, the lower rates of pay in the private sector meant that councils could achieve significant savings through outsourcing this service.”
As for nursing and residential care, the CHPI noted that, “From 1993 central government gave local authorities grants to pay for nursing and residential care and other forms of community care, including housing, but on condition that 85 per cent of the money had to be spent on care homes and other community care services not run or owned by local authorities.
“In addition, successive governments denied local authorities sufficient capital funds to either build or maintain their existing residential care homes, so that as new care standards were introduced – which local authority homes did not meet – large numbers of publicly-owned care homes were transferred to the private sector to own and run.”
Similar budgetary and legislative pressures continue to this day, albeit on a more subtle level. Alongside talk of home adaptations, new websites and remote monitoring technology, the People at the Heart of Care document ominously suggests future funding for local authorities may be dependent on them “paying providers a fair rate” – ie potentially subsidising care self-funders – and developing “market-shaping” capabilities. It also outlines a new duty for the Care Quality Commission to review and assess councils’ performance in delivering care, together with new legal powers for the health secretary to intervene “to secure improvement”.
So it’s hard not to be cynical at this juncture, given the lessons of the past 40 years, and worry about the direction the adult social care sector in England – and the NHS itself – is probably heading. As mental health nurse Lou [see box] says, “I foresee the Tories continuing to sell off the NHS and squeeze it until it is entirely gone. Private companies will continue to make huge profits at the expense of the taxpayer, either through local authorities or directly from people who have saved all their lives, to have their money go on care in their final years.”
Lou – not their real name – is a qualified mental health nurse formerly employed by the NHS and now a manager at a company supplying staff to handle complex domiciliary care packages, mostly funded by local authorities. Here they talk to The Lowdown about the cost pressures and staffing issues they’ve experienced over the past two years:
“Cost is always a consideration when local authorities are choosing providers. We bid to get on to local authority frameworks in order to be in the running to secure care packages. Once approved and on the framework, packages come through and companies on the framework bid for them – it’s a bit like eBay, only in this instance the lowest bid wins and gets the work.
“In my experience local authorities will always opt for the cheapest option, and that is often homecare – until it is no longer viable, the person isn’t safe at home or the cost of homecare outweighs that of a care home placement.
“The sector is always short-staffed. Some of our elderly or end-of-life homecare clients have had to go into care homes or hospital because we can’t always provide the staff needed for their care. And generally, fewer permanent staff means many care homes make up the shortfall with agency staff, which costs double per hour, if not more. We, and many other providers are having to hand packages back to funders because we cannot staff them.
“Care is a notoriously difficult job with low pay and a lot of responsibility, but there was a brief boom of people getting into care at the height of the pandemic because their own jobs had ceased or they wanted to help out. With the end of the last lockdown people have gone back to their original jobs.
“The summer is always difficult for recruitment as many people go on holiday, but this year with Brexit and the lifting of travel restrictions many foreign care workers went home to see their families for the first time in nearly two years. Many will not return. We are not getting the usual numbers of recruits applying, which is entirely due to Brexit, and so there are not enough people willing or able to fill the care jobs needed.”
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