Wednesday, January 4, 2023

How Social Care can help with the current NHS crisis

 The news reports of the current crisis in the NHS are hard to read.  There are no easy solutions, but anyone working in health or social care is aware that Social Care is critical to providing support to our NHS.

The current crisis in part is due to lack of beds and lack of funding in Social Care.

I want to help.  I want to support the NHS to free up beds within our hospitals.  I have been in a position to do so.

I have had two spare beds.  It is the right thing to do to focus on those in hospital who are medically fit to discharge.

BUT.... this is first had experience...

1.  I get daily emails from one of our local hospitals asking for placements for those with moderate - advanced dementia who are medically fit to discharge but who require support with ALL aspects of personal care - washing, eating, drinking, moving.  On December 14 I confirmed I could offer a bed to a person who was fit to discharge, they were a perfect fit for our home for a number of reasons and I was looking forward to meeting the lady.  The fee the nearby Local Authority was willing to pay ---- £650 per week.  They said they may be able to offer more and would get back to me....They never did.  This is for a long term residential dementia placement.  £650 per week would not cover staffing costs alone.  This is also far far less than our Local Authority pays for dementia residents.

BUT it got worst.....

2.  Five days ago I received an email from "Discharge To Assess" - Hospitals local to us had declared critical incident and urgently needed short term placements to enable longer term placements or support to be found for those medically fit to discharge but unsafe to send home.  I emailed on a Friday between Christmas and New Year to confirm I could help.  I called the number over the weekend.  I have called this week to confirm I have places.  It is the right thing to do.  No-one has replied to my emails.  No-one has answered the phone (this is from the Local Authority on behalf of the Hospital) I was hopeful they would be back to work on Tuesday....I still have not heard

3.  All care homes have to fill in a daily "Capacity Tracker" so that hospitals and Local Authority are aware of spare capacity.  I have done this.  It clearly does not work, or no-one uses it.  I know this is not a cost issue as I know I am one of the cheaper homes within the County and we are a "spot contract" provider.

I have kept beds empty to allow for hospital discharges.  But I can wait no longer and so the rooms will be filled with new residents whom we can provide a loving and secure long term home for.  

It breaks my heart when I hear that "there are no beds available to discharge to". 

Surely this would be easy to fix..... why are the discharge teams not speaking to us, and why is there not realistic funding???

Tuesday, August 16, 2022

Looking for Residential Care? Where to start…..


For some time I have been thinking about writing this.  I receive many calls a week from people looking for care homes.  The majority of times these people know very little and ask me to start at the beginning about the care system.  With this in mind and based on future social care reforms taking place in October 2023 (at the time of writing this) I thought this would be useful.   It is fair to say that rarely do people plan to move into care homes, it is generally not the sort of thing the we discuss with our loved ones, or consider for ourselves.  So… if you are looking for residential care / considering it for your loved ones this may help.  This is my personal opinion on how to look for a care home.  (This focuses on choosing care for older loved ones rather than those with learning disabilities or complex health needs)


The decision to consider residential care for a loved one is often filled with apprehension and at times, guilt.  It is a difficult decision and if possible see as many homes as possible.  Remember to put the person who is moving into residential care at the heart of the decision – choose homes that will suit them rather than what you may like.  Without stating the obvious, the care is the most important thing.  Fancy wallpapers / gyms / cinema rooms….are unlikely to improve quality of life. The care and the staff who work in the homes are the most important thing to consider.  



1.      How to choose then….


Without stating the obvious, involve your loved one with the decision.  If they do not have capacity to make the decision, then a Power of Attorney for Health and Welfare should be in place. If it is not then arranging a placement for someone who does not have capacity is much more tricky and the Local Authority / adult social care team and other healthcare professionals will need to be involved.


Make a list of how the person likes to live or used to like to live;

-        Urban or rural

-        Pets?

-        Homely environment or more “hotel” like.  I aim to make our home feel like a home, all who live and work together I regard as my family.  Not all homes are the same, and home like environment do not necessarily suit everyone.

-        Lots of people around or quiet spaces for alone time?

-        Brand new fixtures and fittings and matching crockery (yes, people do ask….)

-        Dementia Home or not?  If people in the home are living with dementia it is important that any residents who do not have dementia are aware that they are living in a home with residents who live with dementia.  I strongly recommend that if your loved one lives with dementia you look for a home that specialises in caring for those living with dementia.  Some residential homes will cope with dementia symptoms to a certain level, but may not cope with all aspects of how dementia can progress in an individual.  


Unless you are going to visit more than once a week please do not rule out homes based on ease of visiting for the occasional visitors.  If your loved one moves into residential care, unless you plan to visit very regularly the most important people are going to be those doing the care rather than whether the journey to visit for the grandchildren four times a year takes one hour or three…….   The important thing is the home suits your loved one, prioritise that above your travel time.


Some new build homes will often advertise “cinemas” “gyms” “beauty areas”.    Ask yourself whether these areas will really be of use to your loved one?  An easily accessible garden, a staff member who will do chair based activities and a hairdresser who visits once a week may be more appropriate than purpose built areas which may be used for marketing… and are likely to considerably increase the cost.   Choose a home based on what your loved one would like NOT on what is important to you.


Super duper en-suites, Wi-Fi access may be important to you, but if your loved one lives with dementia realistically they may not be using the internet and an en-suite forever.


Make sure you meet the staff.  I am the owner of a care home, I think about my residents, staff and the home 24/7, I have access to the realtime care records 24/7,I cover shifts, but I am not there every day, make sure you speak to people who are actually caring, not just the person who is doing the “marketing”.  I ensure that anyone who visits our home meets the staff on shift.  Ask about staffing levels, speak to the staff, ask about the amount of agency staff.    Continuity of staff will be important to ensure your loved one gets to know those who care for them.      Make sure you see the residents – if you are shown empty rooms that should raise alarm bells, what is being hidden?  


But a word of caution, care homes are under immense infection control regulations, depending on Covid rates at the time, visits may not be possible. In this case, ask to see videos or have a zoom video call.



2.      Care Home or Nursing Home?


Residential Care can be provided in either care homes or nursing homes.  The CQC (Care Quality Commission) that regulates all healthcare providers will register a residential care provider as a “Care Home” or “Nursing Home”.  Nursing homes must have registered nurses on site 24/7.  Care Homes do not have registered nurses on site at all times.  Nursing homes can therefore provide care for those with complex medical needs.


However, when it comes to Dementia, care homes or nursing homes may be considered.   


Dementia Care is often provided within Care Homes. Previously called “EMI – Elderly Mentally Infirm” this is not a description which is used nowadays  (this meant the home specialised in the care of those living with dementia) and as such it is hard to differentiate homes that specialise in the care of those living with dementia.  Some care homes will not be able to provide care for those living with moderate / advanced dementia symptoms, some may not be able to care for those with significant mobility issues (requiring hoisting to get out of bed for example).


Some care homes will have separate “wings” for those living with dementia, other homes will have all residents in the same areas and will not segregate based on level of need.  


When considering a home, remember this is likely to be your / your loved ones last home.  Find out what level of need the home would not be able to cope with.  Go into specifics about this – you do not want to find out that a home is unable to support your loved one one / two / three years in the future.  


3.     Funding!


If an individual has savings or assets over £23K then, at the current time, they will have to fund their own residential care.  If an individual has a home then this is considered within the £23K limit (although not if they have a spouse who is still living in the home.  Continuing Healthcare (“CHC”) is sometimes provided for those with very complex needs who require nursing care and this is fully funded by the NHS,  However, the thresholds for eligibility for CHC are very very high – advanced Alzheimer’s does not normally meet the thresholds.

However as of October 2023 the rules change!  At the time of writing a Local Authority will contribute to part of care costs if someone has assets under £100K AND there will be a lifetime limit on care costs of £83K.  But this is just the cost of care – not accommodation / food / utilities.  As an example, if an individual is paying for residential care of £1000 per week, probably around £600 of that will be the cost of care, so the £83K lifetime limit would apply to care costs, not the full weekly fee.  

BUT… no fees will be paid / costs of care considered unless the Local Authority is aware of your / your loved one’s needs and have essentially confirmed that they require a residential placement.

  If you are looking for care, or you have a loved one in a residential setting at the current time who is self funded it is essential that you ensure the Local Authority are aware of them.


In terms of costs, there can be huge variety in costs.  I do not believe that cost equals quality of care…..


4.     CQC Ratings / Reviews / Open Days


CQC reviews should always be read, they will give an overview of the home.  BUT… do not get too hung up on the ratings.    I have personally visited homes with “Outstanding” ratings that I would never consider recommending, and I have also visited homes that are “Requires Improvements” that I would recommend.  Inspectors have a very difficult job to do, and see a snap shot of a home at a moment in time, some of the big chains of care homes have people who solely focus on how to get brilliant CQC ratings,….   Read reports in full and decide whether you share the same concerns or whether a report is perhaps “too good to be true”.


Reviews can also be “created” and unlike trip advisor / trust pilot generally negative reviews are not as widely accessed or provided.  So take all reviews with a pinch of salt.


If a home has an open day it means they are desperate to fill beds.  This is not necessarily a bad thing, but it should raise some questions,  generally there is a shortage of care home spaces, a home with lots of vacancies may not be a good thing.  If you go to an open day, make sure you speak to people who actually do the caring, not a marketing / front of house team. 


5.     Respite or short stay?


I get tens of calls a week about respite stay, particularly in the summer.  This is something we rarely offer, respite stays are in high demand and there are not many available, particularly for those living with dementia.  It take a few weeks for a home to get to know the resident and for the resident to get to know a home, respite stays can often be unsettling and should be considered carefully.


BUT… I always say to new residents and their families to view a move as a respite stay – if they don’t like us, then there is no lengthy notice period, ensure that this is in place with any new home.


For someone living with dementia who may have some awareness of a move, but not their level of need, I suggest that any placement is initially communicated this way to the individual. 


6.      Start Early


The amount of times we receive calls when people say “what do you mean you have no rooms”.  I have even had one person turn up outside our door because “Well I thought seeing you in person may mean you find us  a room”.    Understandably people often do not start looking for care homes until they are desperate, and then they may not have many homes to choose from.


Particularly if a loved one has dementia and you think they may need care in the future, please start looking now and start speaking to lots of homes..



7.      And finally


Expect to be “interviewed”.  Not only do I want to learn about the resident, I want to learn about the family and visitors.  Whenever a new resident moves in there is always a period of adjustment for the resident, but also for their families.  We expect lots of calls, and we are on hand to guide you and support you through the transition.  However, sadly this can often at times mean that a well meaning loved one can be somewhat demanding, and sadly this can often be directed at more junior members of staff.  My residents and staff are my family and as such I want to ensure they are happy, safe, loved and respected.  Any good Manager / Owner will also be interviewing you to ensure that you will fit with the home.  


Get to understand the structure of the home, ask who is onsite at all times.  Is the Owner available at all times, do they know what is happening?.  Does the Registered Manager spend most of their time on the floor with the residents – not hidden in an office?.  In my opinion I feel that anyone managing and owning a home should be involved and hands on, and you should be able to contact them direct.


I hope that this helps, remember to put your loved one and their needs at the centre of this decision.


Sunday, May 8, 2022

Your family has to wear a facemask at home... at all times.....

 Two years since the start of the pandemic.  

We know that those that live in care homes are particularly vulnerable to Covid.

We also know that Covid is airborne, and once Covid is in a care home it spreads.

We understand about Infection Protection and Control.

Residents in care homes have received Covid vaccinations and two boosters.  

We have done, and continue to do, all we can to protect our residents, but we now have to focus on making our residents lives as happy and content as possible.

We strive to make care homes a home.  Not a hospital, not an institution, not a regimented routine filled controlled sterile environment.

Our care home is a home, the residents are part of my family, the staff are part of the family.  Our care home is full of love, laughter, friendship, sometimes noisy, sometimes quiet.  Full of residents family and friends.  It is our residents HOME.

So.... two years on.... imagine if you were told that in your HOME your family have to wear facemasks at all times,  everyone you see has to have a facemask on.  This also of course means that you can not enjoy a meal, snack or drink side by side with anyone in your "family".

Two years post the start of the pandemic life outside care homes in the UK is pretty much back to normal. Those who live in care homes only see masked faces of those who support them, protect them, love them and care for them.  

Guidance is explicit for all of us who work in care homes - we have to keep our masks on at all times.  For those who visit, the guideline states it is "encouraged", but if providing personal care full PPE is required. Yet, if our residents leave the care home, no facemasks are required.

Does this make sense to you??

Monday, March 7, 2022

Covid and Care Homes - Four things I believe


  • The restrictions in care homes are now more dangerous than the virus itself


  • Life needs to now return to normal, and Covid should be treated as a disease along the same lines as flu.


  • The government needs to listen to the care home community – how care homes interact with government officials needs to be streamlined to drive efficiency and not bureaucracy. 


  • People with and without dementia need to be treated differently and can’t be bucketed into one care home community,


I have now seen first hand the devastating impact on residents wellbeing from being isolated in their bedrooms.   Testing, isolation, visiting restrictions, definitions of “outbreaks” within care homes.  I spend hours and hours each week writing policies, guidelines, filling in forms for the Department of Health, answering questions from Local Authorities.   All the time doing this I could spend with my residents, supporting staff, speaking to families.  I don’t feel supported by the Government, I feel let down.


The vast majority of Care Home Owners and Managers want to support and encourage visiting, we want life to return to normal for our residents.  In the last few weeks restrictions have lifted for the general population, but for care homes we are under inconsistent stringent rules;


1.      Just two positive covid cases warrant an outbreak, and as such this means that we have to close to all but just one visitor per resident.  Homes also have to isolate vulnerable residents to their rooms, and due to the risk of this homes are unable to take new admissions, including hospital discharges.

2.     We know testing is far from infalible, but if it is required, then the costs of tests should not be paid by visitors.

3.     NHS frontline staff (including A&E and district nurses) are required to test twice a week, all social care staff are required to test before every shift – why the inconsistencies?  It has to be remembered that all social care staff from 11 November 2020 legally had to be double vaccinated.  This was proposed for NHS staff but as we all know, this was then postponed in April due to concerns about loss of staff.  All those who worked in Social Care shared the same concern, but our concerns were not listened to....until a sudden U- turn last week (too late, tens of thousands of care staff had already left).

4.     The Department of Health / Health Protection Agency needs to consult with care home owners, and it needs to listen.  There is a woeful lack of understanding about the needs of residents within care homes and the catastrophic impacts of the current guidelines that are in place.


My experience of an outbreak came a little over six weeks ago when Covid entered our home I have to admit that after two years of remaining outbreak free, I felt proud.  I knew that we were doing all we possibly could to avoid the virus entering the home.  I was aware of every piece of guidance, we were testing more that was actually required. Our visitors process was stringent. 


We followed every rule, we were rigorous with testing, but Omicron found a way in.   Two cases in a 14 day period, either staff or residents are defined as an outbreak as per Health Protection Agency rules.  Two staff members tested positive three days after working, despite negative LFT’s at the start of their shift.  A day after they tested positive, we tested all residents, three residents were positive.  We have no way of knowing whether the residents gave it to the staff, or the staff gave it to the residents (those residents had been having visitors).


We felt prepared, we had outbreak plans in place.  We knew what had to come next.  Nothing could have actually prepared me for what happened next.  Within a seven day period half of all staff and eleven out of eighteen residents tested positive.    Staffing levels were stretched, but as a team we pulled together, the “Business Continuity Plan” was enacted.  We maintained safe levels of care and I am proud of what we achieved.  But, I have never known physical and emotional exhaustion like it and it is an experience I never ever want to repeat.


The brilliant news is that, thanks to triple vaccinations, all staff members who tested positive were either asymptomatic or had mild to moderate symptoms.  All were back at work within 10 days. Of the 11 residents, all made a full recovery.  Some were entirely asymptomatic (in the middle of the pandemic I was frequently told “there is nothing wrong with me, this is ridiculous” by one 99 year old resident who was desperate to come out of her room, she was entirely without symptoms despite testing positive). Some residents were poorly, but all apart from one has fully recovered, one is not back to her previous health, but this would have been no different to her getting a cold / stomach upset.  However, I fear that the longer term impact due to the isolation for two weeks in their rooms on some of the residents will be more detrimental than Covid.   For those who live with moderate to advanced dementia, being isolated in their bedrooms for even a couple of days has significantly negative impacts.


I have however had time to reflect and digest the experience.  I am left, frustrated, angry and let down by the Government and Department of Health.


Every single day I need to complete something called a “Capacity Tracker”, this centrally reported database tracks resident occupancy, staffing levels, sickness, testing, sickness pay, how staff travel to work (!).  Since having an outbreak as a home I am now under the spotlight.  I don’t feel supported, I feel checked up on.    What has become crystal clear is that that the Department of Health is woefully lacking with its understanding of care homes.    Each week I am called by the Local Authority, I have to answer questions about numbers of staff testing and residents testing – I am told that this is to “check track and trace data”.  I am then questioned about staffing levels, testing and infection control training.


In the midst of our outbreak I had many calls with the Health Protection Agency (previously Public Health Team but in the middle of a pandemic they decided to change their name).  I asked questions and required support.  Of course these calls and emails could only be answered on working days between 9am and 5pm... .  I took a call from a Health Protection Agency member who was concerned about the infection level.  This is how the call went;

HPA “Can I confirm you are following all PPE guidance and donning and doffing correctly and all staff have been trained ”

Me “Yes” (I did not have time to take the call I was caring at the time)

HPA “Can I confirm that this happens at ALL times”

Me”Well, can I give you  an example – D (who has dementia, has tested positive and is mobile) comes out of her room frequently, her movement mat sounds to tell us she has left her room.  I am with another resident.  I leave the other residents and run to D.  She is moving along the corridor going into another residents room.  Should I spend 20 seconds putting on a different flimsy apron and new nitrile gloves and visor while she wanders into two or three other resident’s bedrooms, or should I go to her straight away, hold her hand, reassure her and take her back to her bedroom”

HPA …. Long pause….. “Hmm, yes that is a challenge, but you must keep PPE on and don and doff correctly.  Can I ask, have you taught your residents hand hygiene and told them how to clean their hands and also told them to put on a mask”.


Aside from the fact that as a 90 year old woman, teaching someone how to wash their hands could be construed as entirely patronizing, the lady in question has advanced dementia, and would definitely not be able to follow instructions.


The list went on…. On another call I was told that I should move residents to different bedrooms to keep those with covid together in one area.  Can you imagine moving residents with dementia to different rooms in the middle of an outbreak when staffing levels are stretched in the extreme fai.liming to consider the impact on the resident.


The Local Authority called me during the outbreak.  They had no suggestions, other than “call an agency to get agency staff if you have staffing challenges” but they did have another form for me to fill in….   They will be visiting next week, undoubtedly to check my infection control processes.


But, the outbreak is over and I hope that immunity levels are now very high as a number of residents and staff have had Covid in addition to triple vaccinations.  Several of us, despite being exposed to covid on numerous occasions during the outbreak have remained covid free.  Lateral Flow Tests are not infallible – people were positive on PCR’s and negative on LFT’s and people.  Some residents we know were infectious prior to LFT’s turning positive.


On February 9th our outbreak was declared officially over and visiting resumed – not just for essential visitors but for everyone.  On February 23rd the Government released it’s “living with covid” guidelines, outside of care homes life returned to normal.  Care Homes are still subjected to testing, visitor restrictions, PPE.  Our most vulnerable is society are being “protected” from a virus that may possibly kill them, but so would a cold, stomach virus or other infection, but their mental wellbeing is not being considered.  I want my residents to see their loved ones, to hold hands, to cuddle their grandchildren, to see my face.  As a carer, I want to care, and I want to enjoy a cup of tea and a piece of cake with my residents…something I have not done in two years as I am now allowed to take my facemask off.    A cup of tea, a cake, holding hands -  Is that too much to ask?


The protective ring of steel around care homes now feels like an ever tightening noose.  




Monday, January 17, 2022

A simple example... and a (very) long "EPQ"

 "Social Care Reform". It is written about a lot.  If you are reading this, you probably know a little about it.   My daughter is taking her A-Levels this year.  She was required to do an "EPQ" (Extended Project Qualification).  It's about Social Care Reform, and it was handed in last week.  She asked that I share it on my blog.  Here it is.... copied and pasted below.....  

But from me......why is Social Care Reform required? ......  A few weeks ago we sadly lost a resident who died peacefully in our care home, with her family and carers, all who loved her, at her side.    

She has lived with us since 2013 - almost 8 years.  Her placement was funded by the Local Authority. In 2013 we were paid £2715 per month for her care.  In 2022 that had increased to £2897 - a 6.5% increase in eight years.

In 2013 the minimum wage was £6.20, it is currently £9.50 - a 53% increased in eight years.

The funding provided by Local Authorities is woefully inadequate and in most cases barely covers the cost of staffing, let alone food, accommodation, heating etc etc.

Fees have no way increased in line with inflation, wages and cost of living.  Care Homes quite simply can not afford to provide care to many people who are funded by Local Authorities as budgets have not kept pace with the cost of care.

That's my simple, real life example....

Now, over to my daughter...... 


Adult social care covers providing personalised, practical support for people over the age of 18 whilst preserving dignity and helping individuals stay independent. However for the purpose of this paper I will be focussing on social care for older people in a residential care setting, which accounts for 65% [1]of the yearly adult social care budget. Adult social care reform is a topic that frequently is making English headlines as politicians and citizens try to fix an issue of vast underfunding that has been left on its own for too long. Each year the ideas for reform are discounted due to many reasons or the whole topic is ignored completely because it is seen as too difficult. However this strategy is causing the situation in the sector to worsen every day when nothing is done. People in need of care are not receiving it, carers are turning their backs on a career and care homeowners are having to shut down entire facilities as they are unable to keep their business alive. We hear about this on the news most days, but nothing is being done. That is why, within this essay, I will be exploring why he need for a social care reform is so great and why the decision can no longer be delayed.


There have been many reforms and changes which have been proposed but never implemented. This raises many questions as to whether politicians actually care about changing social care or whether their proposals are purely for their own political gain. Or is the question we should be asking whether the public want a reform in a sector crying out for one or have they developed a sense of apathy that it is someone else’s problem? No-one likes to think about death and culturally, our society choses to ignore the ideas of growing old and what will happen in the future. To understand the necessity for a reform in social care, it is necessary to understand the reasons for the problems in social care. 


To be able to comprehend the necessity of a social care reform it is crucial to understand the history of social care. In 1942, the ‘Beveridge Report’ was published which was one of the first inquiries to begin to address the idea of adult social care. The incoming labour government of 1945 began to built the foundation for the 1948 National assistance act, which led to the monumental creation of the welfare state. This act began the development of an insurance based system for health services, with a focus on unemployment support. Even though, this was a huge step towards the implementation of greater support for adult social care, it wasn’t enough. Towards the beginning of the 1950’s, the general consensus of the English population was that it was necessary to support older people so that they could remain in their homes for as long as possible, promoting the ideas of keeping an older persons independence, which we still see in the core beliefs of adult social care today. 20 years on from on this, in 1970 the nation saw the implementation of the Local Authority (L.A.) and social services act. This established an integrated local authority social services department in England, not dissimilar to the local authority service that is still provided today. Following on from this, in 1978, a paper was published entitled ‘A happier old age’ which began to set an agenda for a wide ranging debate about the care of people as they are in the last stages of their lives. It began to develop a long term strategy to ensure well-being and dignity for all older people; unfortunately, 40 years on, this topic is still being discussed and no conclusion has been made. 


At the end of the century, in 1997, the Royal Commission was established to explore long term funding options for care for the elderly (once again, a debate that is still being had 20 years on). At the turn of the century, in 2000, the Care Standards act was published to build a commission for social care inspection. This act made sure that by registering different local care services, all providers would be required to meet national standards, similar to the Care Quality Commission (CQC, an organisation which regulates all the health and social care services in England) recently implemented across care providers in England. Finally, in 2001, the National Service Framework for older people was established to improve the quality and support social care providers were able to provide. This framework was centred around 4 themes ; Respecting the individual, Developing intermediate care, Evidence-based specialist care and Promoting healthy active lives. Despite this brief overview, it is clear to see that changes and conversations about the system over 40 years ago are all too similar to the debates being had today about the progression of social care. Surely we are not in the same position we were when the welfare state was first introduced in 1942? 


There has been 13 documents on reform in 17 years, 4 independent reviews, 4 consultations, 5 white and green papers and yet it still feels like little to no progress is being made. All over the news and media it is constantly being highlighted that adult social care is in crisis and things need to change, but when and how will this change happen?. Once again, to understand our current system of social care and why it is desperate for a reform, it is vital to understand some reforms or policies that the government had tried to implement in the last 11 years. In 2010, during Labours election campaign, they proposed a consideration of taxing people’s estates to pay for social care. Unfortunately, as will be seen as more of these reforms are outlined, policy ideas become politicised too quickly. The truth is unpalatable for the public as the associated costs are so high and so far no government has been transparent about the implications on taxation. This policy was dubbed the ‘death tax’ by the Tory party, as a warning to the public about the impacts these highly progressive policy ideas would have. Later in this paper, I will explore the main reasons for the failures in social care and one of these is the politics surrounding reform. Progressive ideas become politicised by other parties but doing nothing matches the majority of the public’s apathy.


One of the most influential reforms which was proposed was the Dilnot commission of 2011. This commission was centred around a reform in the means test system and a cap on the lifetime cost of care which a person may face. The Dilnot commission report that 10% or older people will have care costs which would accumulate £100,000 or more[2]. The commission’s proposal was a life time limit of £35,000 which people should be spending on care and the threshold for the value of limits should be raised to £100,000. Today, that’s £35,000 limit would account for a little more, on average, of 1 year of adult social residential care. Despite these ideas, the implementation of these reforms was initially delayed and then postponed indefinitely. It was argued that there was no hard data that these proposals would offer sustainable support for the future of social care. Throughout history service users have stated that the only way to fix the gaps in adult social care would be to implement a general taxation on the public. Furthermore, it was estimated that these proposals would add £1.75 billion [3]per year onto the social care budget. Another highly political proposal for change in policy was the Conservative ‘Dementia Tax’ proposed in 2017 which indicated that no matter how large the cost of an individual’s care is, the individual would always retain £100,000 of their savings and assets[4]. However, this didn’t include a lifetime cap on contributions to social care. This could mean that wealthy individuals could end up spending vast quantities on residential care, for example for those living early onset dementia who may require decades of care. As we saw with the labour policy, this proposal became highly politicised and Theresa May lost her majority in Parliament for her failure to consider the public opinion on what was seen as penalising those living with dementia. 


The publication of the 2012 white paper[5] was seen as a step in the right direction for adult social care. However the guardian paper titled it ‘a policy disaster but a political victory’. Once again, politicians seemed to be giving adult social care the focus it needed, but when the paper was looked at there seemed to be no understanding of how the ideas proposed would be implemented or a clear idea of the economic costs. This paper focused on a person-centred system with 5 very broad, extremely vague ideas; improved accessibility, high standards of support, providing people with the help they need to stay active, connected and independent, more training and development opportunities and finally, putting people in charge of their care and support opportunities. At a quick, first glance these aims seem reasonable but as mentioned, there was no ideas for how these would be implemented or what real changes would be seen and what the associated costs would amount too. There is little to no significant changes that can be seen from this white paper. 


In 2013, George Osbourne proposed a financial bill which proposed a life time limit of care costs at £72,000 with a threshold for assets at £128,000. Once again, this idea was never implemented as it was budgeted to cost an extra £1 billion[6] per year which would continue to rise with the changes in economy and population. It is clear that people want to see change in the adult social care system, but most are not prepared to pay for it. Changing the system requires money in the form of taxation. Finally, most recently in March 2021, there was wide spread uproar in the community when in the queens speech there was a single line given to social care; ‘Proposals on reforms to social care will be brought forward’ in the next month, the budget was announced with no reference to Social Care. Despite Boris Johnson’s first speech as Prime Minister in 2019 where he stated that he would ‘fix the crisis in social care once and for all with a clear plan we’ve prepared’[7]. There is still no indication of when this plan will be published. 


In my opinion there are 5 key issues that need to be addressed: Cultural and demographic issues, Staffing Issues, Funding (in particular that of Local Authority), Disparity and the Politics surrounding social care reform.


Firstly, for there to be the necessary steps taken towards the changes in adult social care reform, the demographic changes in England need to be addressed and there needs to be changes in cultural attitudes. There has been a growth in demand for social care reform, primarily due to demographic changes. We are currently in what is known as a “demographic bulge” as the baby boomer generation are reaching retirement in the early decades of the 21stcentury. In 1953 (when the welfare state was taking form) there was only 200,000 people over 85, but in 2016, there were 1.6 million people over he age of 85 and this number is expected to double in the next 23 years[8]. In addition, currently there are around 59,000 people over the age of 100 and in the next 23 years, this number is expected to double[9]. Most worrying of all – in a 2017 study – it was estimated that if rates of people needing care remains consistent, there will be an additional 72,000 residential beds in care homes needed by 2025[10].


In order to address these demographic changes, there needs to be significant change in not only people’s interest in their future, but also their understanding of how the system works. It can be argued that the population has become apathetic towards social care because people don’t want to think about what happens when they reach an old age due to the public’s general fear of death and being incapable to look after and provide for themselves. There is very minimal education and discussion surrounding a system that almost everyone will need support from at some point in their lives. People do not take the time to educate themselves about how the system works and in particular how their care will be funded. Many studies have been proposed to the public where it is extremely clear that the public assume that the current funding system is more generous that it actually is. Due to individuals personal experience, they may have ideas, but these ideas change from person to person. Furthermore, some people assume care will be free at the point when it is needed where as care is only paid for if the assets of an individual fall below the threshold of £23,250 (which many don’t know that this is the number for the threshold) and even then care is only partially paid for. Due to this, every year, at least 30,000 people [11]are having to sell their homes in order to pay for their care. Unfortunately any proposed solutions require public investment, but any solution which requires extra spending on their behalf is perceived negatively by the public. 


More broadly, people are unaware of how to access care. Some assumed the GP was their entry point and when asked, Local Authorities were rarely acknowledged. People with major experience with the sector appeared to have more knowledge but they were still not confident about how the wider system functions. As it can be seen, for even minute steps to be taken in the direction of an adult social care reform, their needs to be an acceptance of our changing demographics and how the system can cater towards this, but also a drastic improvement in the public understanding and their acknowledgment of how the system works.


In my opinion, one of the most prominent cause for the issues in social care is staffing. The issue of staffing in the sector is something that is always reported about, but still, nothing has been done about. This issue covers so many different areas; the way the media portrays care staff, uptake and retention of staff and pay. The future of the care work force is bleak and ageing. The average age of a care worker is between 44.[12] Young people rarely aspire to work in the care industry. In March 2021, Rishi Sunak described social care as a “problem”. At exactly the same time, the Department of Health and Social care was launching a recruitment campaign… who wants to work for an industry that the government openly refers to as a problem? The combination of these different factors is causing detrimental problems for adult social care. This job needs to appear more attractive and stable. One of the two ways of doing this would be too firstly limit the amount of zero hour contracts to giver the work force stability. Secondly, caring needs to no longer be regarded as unskilled which I will go into more detail about later.


 One shocking statistic showing the difficulties of this job is that as of May 2017, suicide rates among care staff were twice the national average.[13] This in part, is likely to be due to high pressure, emotional fatigue, long hours and low pay. 


Firstly, there is far too much negative stigma around working in care; media portrayal and public perception is rarely positive. During the changes in legislation following Brexit and the jobs which were open to foreign applicants, the role of a carer was missing. Care is not regarded as a skilled role. From an academic point of view, to work in care grades carry less importance. The qualities of empathy, compassion, kindness, strength, energy, flexibility are required to provide end of life care to a non-verbal, non-mobile person living with end stage dementia. Yet still this role is regarded as unskilled. The majority of media reporting about this job is about abuse, laziness and general unhappiness with the career. It is vital that good quality of work is praised more than bad quality work is portrayed. A care worker can have a job for life because there is always a need for good quality care staff. The relations built and developed within this job are unmatched with many other jobs because as a care worker, you gain very strong relationships with the residents or patients you care for and the people who you work with. 


However, unfortunately the relationships developed (in particular the relationships with residents) are capitalised upon. You can not put a financial value on care and these relationships cannot be bought. The sector is constantly caught in the crossfire between commercialisation and the understanding of what care is. There is too much focus of the value of money in care. How can you quantify the cost of how long it takes someone to die and to provide person centred care? Care recipients are known as service users, which they are not. Providing care cannot be seen as transactional, which is why it is very difficult to quantify the costs associated with it. Care is not just about practical issues; It is about developing a good quality of life for the individuals who require care. 


There are 122,000 vacancies[14] currently. In 2020 there was a 6.6% vacancy rate with a turnover rate of 33.8%[15], in comparison to the 2017 turnover rate of 27.8%[16]. It is estimated that there will need to be 520,000 extra staff by the end of 2035 [17]to keep up with the demand for care. One of the main issues with the uptake and retention of staff is that so much more money is put into the NHS for attracting new workers that working for the NHS becomes a much more attractive career path. As Caroline Abrahams argues “It is high time that the situation changes in which care staff are constantly the poor relations of their equivalent in the NHS”.[18] One issue with the uptake of staff is that many young people will do courses in health and social care, but this is not translated into the amount of young people following a career path into adult social care. 1 in 5 young people are asked to consider a job in the sector but only 1 in 25 people will apply[19]. Most shockingly 1 in 10 young people under the age of 40 will stay in their job as a carer for more than a year[20]. I was lucky enough to have a conversation with a care homeowner who told me that she was trying to hire more staff and had 5 applicants, but none of the applicants showed up to the interview[21]. It is stories like this that highlight the issues in staff uptake in the sector because it is clear that something has to be done to change people’s perception of this job.


The final main issue with staffing in the sector is the very low rates of pay that staff receive. Pay has risen as  a result of changes to the national living wage but care workers are still paid less on average than shop assistants. More than 25% of all care staff are on zero hour contracts, [22]increasing the instability of their job. For many it feels very different for there to be progression within the job because staff with 5 or more years’ experience are now paid on average only 15 pence more than new entrants[23]. The proportion of staff being paid minimum wage has increased from 10% in 2016 to 30% in 2020[24]. It is easy to put the blame on the care home owners for low pay but after speaking to another care home owner they shared with me the statistic that for local authority funded residents they are paid £695 per week to provide all care. The cost of staffing is £672 per week, per resident. That leaves just £22 per week for accommodation, food, power and everything else. It is therefore easy to understand why care homes on this basis are unable to increase pay rates as local authority funding has not increased, even in line with increases to minimum wage[25].


Adult social care is a system that is chronically underfunded that is caught in a consistent loop of scandals leading to increased regulation and inspection, but rarely leading to an increase in funding. Unfortunately, as I have mentioned, any plan to improve the sector will require a large increase in funding and the constant squeeze placed on the funding is affecting the stability of the market. The care sector has increasingly high demand with an average growth rate of 3.7% per year[26]. However, between 2010 and 2018 there was an 8% cut in social care[27] budgets accompanied with a reduction in beds as so many care homes were closing. There will undoubtedly be a funding gap between care required and care available but it is unclear of how much a funding hap will leave. Some sources state that this increase will leave a funding gap of £6 billion by 2030 and other sources say this gap could be £18 billion by 2030. This uncertainty shows how difficult a system it is to value and fund, but also shows that no matter what changes, the system needs more money pumped into it. 


Cuts in local authority spending are a main reason for the lack of money in the sector. Between 2010 and 2008 there was a 49.1%[28] decrease in government spending for local authorities, significantly limiting their spending power. In total there as been a £216 million reduction[29] in local authority spending in elderly social care. Local Authorities are not being given enough money to implement the care act  to ensure that good quality of care is being provided for service users. Care homes with more than 75% L.A. Funded residents are at the highest risk of failure. This makes up around a quarter of UK care homes[30]. There are many local authorities that are paying care provides the absolute minimum price which is regarded as necessary to comply with minimum employment and care standards. However, as stated earlier, how is it possible to quantify the costs of care on an individual basis.


As I will go onto to talk about in greater detail, the disparity in the sector is growing more and more abundant each year. The gap between needs and the funding available is widening and the provider market is facing severe and sustained financial pressure. In 2019, ADASS reported that 75% of Councils (up from 66% last year) reported that providers in their area had closed, ceased trading or handed back contracts in the last six months, with thousands of individuals affected as a consequence[31]. These closures are being felt throughout the country leaving vulnerable people unable to access the care that they need to maintain their health and livelihood. In 2017, commercial analysts estimated that a 1/3 of the UK’s bed capacity in residential care was at risk of closing in the next 5 years[32]. The surviving care homes may be tempted to push prices up. Further disparity is seen between self funders (those who pay for care themselves) and L.A. Funded residents where a self funder has the average fee of £846 per week and a L.A. Funded resident has an average fee £621 per week[33]. In comparison with the NHS, everyone contributes to their care via tax, where as there is no such system in place for social care. If you are diagnosed with cancer you won’t have to pay for your treatment. If you are diagnosed with dementia you will have to pay for your care. 


As has been seen in previous parts of my essay, the disparity that the adult social care sector faces is abundant and growing fast. Like I mentioned, the disparity between the NHS and adult social care is what the majority of the public fails to understand. However it has had more exposure  throughout the COVID-19 pandemic. I have chosen to not make lots of references to the pandemic because it has been something so out of the ordinary that has exacerbated the problems as it was something so unexpected whereas I wanted to delve into the deep-rooted problems in adult social care. I have chosen to make reference to one part of the pandemic as I feel as though it emphasises the disparity between NHS and social care very clearly. From early November 2021 it was mandatory for all care staff to be double vaccinated, many were not and therefore lost their job, further exacerbating the staffing issues. NHS staff have until April 2022 to be vaccinated. In addition, a letter was sent to all care home owners explaining that ambulance drivers do not have to be double vaccinated but they legally have to be allowed into a care home. Family members who are not double vaccinated are not allowed into care homes. So why? The answer is not clear. This highlights the differences between how the public and government views the two sectors. The NHS has time to make the choices where as social care is rushed into mandatory vaccinations which for this sector was a nightmare. The belief of those working in social care that they are the Cinderella of healthcare, was coming through. Social care was an easy target for the government to force upon legislation. However, they would never be seen to do something like this to the NHS as it is thought of so highly by the general public. 


Furthermore, there is also disparity within the sector among quality in particular. Quality of care is variable and inconsistent. In a survey published before the 2012 white paper, only 43% of people in England that the people using care have access to good quality care where they are treated with dignity and respect[34]. People wanting to access care are also at the pitfall of what is known as ‘the post code lottery’ where dependent on where you live, the price of care in a care home setting changes drastically. In a recent research paper published by the institute of public policy research it has been discovered that 80,000 care home residents could be receiving care in their own homes where they will have an increased independence with more fulfilling lives. The proportion of care provided at home varies considerably across different councils. In Barnsley it is as low as 46% and in Hammersmith and Fulham it is as high as 84%. As Chris Thomas, the leading IPPR senior research fellow argues, ‘Government needs to think ‘how care is delivered to ensure people can lead flourishing lives, regardless of arbitrary factors like where they live’ This difference across the country shows that these disparities are not in an isolated section of the country, the occur nation wide[35].


The final cause that I feel needs to be discussed is the politics surrounding changes in adult social care reform. For years and years, the unwillingness for politicians to make sustainable and substantial change has been seen through approaches and decisions taken. There is the issue surrounding an idea of ‘the politics of doing nothing’ [36]categorised by and absence of government action rather than a failure of any action. Reforming adult social care seems like an issue that can never be solved by politicians because if there is a policy failure this will also lead to a political failure. There never seems to be a true search for an ideal solution, the government is only looking for solutions which will gain them votes in parliament. In a country where political and ideological standings are part of the framework, the potential for shifts in individuals political leanings is detrimental for a parties political image. Especially surrounding a topic such as adult social care where there is the potential for significant damage to the system. The reform of adult social care is seen as a ‘wicked [37]issue’ which is complex and multi-causal because there is no singular root to the problem. The governments approach to welfare reform has always been to try to make people and problems go away by cutting services and support rather than increasing financial investments. 


As previously stated, adult social care is caught in a vicious policy cycle where no one knows what to do or what to avoid doing. Adult social care can also be seen as a policy chestnut which resurfaces every few years, extensive analysis and reviews are undertaken, various options are considered but any proposals are rejected. This issues are marked as too difficult and the country and government becomes stuck in a continuous cycle. Government is trying to develop a non-partisan, cross party solution but this is nearly impossible because there will never be a solution that every politician and citizen will agree with. As Sally Warren, King’s fund researcher argues ‘The political consequence of fixing social care is incredibly unpopular. It is much more straightforward politically to keep kicking the can down the road’[38]. Adult social care reform is overshadowed with uncertainty, confusion and turmoil. It is the elephant in the cabinet room. 


These 5 causes: Cultural and demographic issues, Staffing issues, Funding, Disparity and Politics are rooting the problems of adult social care deeper and deeper into the framework of our country. It is becoming an issue that people don’t want to think about because these causes remain unchanged and nothing is being done to ease the pressure. If no action is taken, there will not only be devastating impacts to the adult social care sector, but also detrimental impacts that will spill over into the NHS and wider sectors. People may not be able to go to work as they are having to stay at home to look after an older vulnerable loved one, 


As these gaps widen and he sector falls further into disarray, we will continue to see a rise in the fundamental differences in funding between the NHS and the adult social care sector. People needing care will begin to be routinely stuck in hospital waiting for the appropriate care they need, taking up beds (bed blocking) from people who are in desperate need of hospital treatment. In addition to this, the country will see a rise in hospital discharges going to the wrong sort of care too early, meaning that care receivers may need to go back into hospital, continuing this vicious cycle or bed blocking and improper discharge. Imagine that you were an old person with dementia. The detrimental impacts this can have on a care recipient well being are devastating and cases such as these will only increase if no action is taken.


Furthermore, due to the L.A. Facing a sustained increase in costs we face the severe risk of the privatisation of care homes because care/service providers will be unable to provide care at a reasonable cost for the neediest in society. There are 2 risks from this. Firstly, this could mean that only the top percentage of self funded recipients will get care at care homes meaning that this who are council funded (typically pay less to the care provider weekly) will be unable to revive the appropriate care they deserve. Care providers/companies have to make a profit, or they face complete bankruptcy. Secondly and most devastatingly, the country will run the risk of the loss of care homes completely because there is not enough money in the sector, meaning that homes are unable to remain open. More widely there is the risk of the already crippled NHS having a complete collapse because if care homes can’t stay open there will be a mass influx of vulnerable older people needing care.  This will lead to the people needing medical care not being able to receive it putting the wider country at massive risk. 


The reason that adult social care needs a reform and extremely urgently is the uncertainty. It is impossible to put a number on how much this reform will cost the economy or how long left we have before the timer runs out. What we do know is this. As of 2019, the government was spending £27,000 per hour for social care discharges [39]and this number will continue to rise and will not stop. 75,000 more beds will be needed by 2030 [40]and this number will continue to rise and will not stop. Adult social care needs to be reformed now and the longer the country and sector carries on without this reform, the worse the impacts will be in the future. 


All these things which I have explained paint the picture of the harsh reality that adult social care faces today. These ideas and issues are things that have stemmed from the past but will not stop and will continue to carry on to the future, bringing with them a whole new set of issues for the society at the time to deal with. We should not be kicking the can down the road and taking the issue of adult social care reform as someone else’s problem. It is a problem that our society today can solve and needs to solve before we risk future generations having limited or no access to the care that is guaranteed to them. Everyone in society wants to be treated with dignity, respect and care in their old age. The government therefore has to be brave enough to ensure that the public understands why it is so critical that adult social care receives the funding it is gasping for.

[1] Kings Fund. Key Facts and Figures about Adult Social Care. [online]  Available at [Accessed 29th December 2021]

[2] Peter Lilley (2021). Solving the social care dilemma? A responsible solution[online] Available at [Accessed at 26 May 2021]

[3] Peter Lilley (2021). Solving the social care dilemma? A responsible solution. [online] Available at [Accessed at 26 May 2021]

[4] Alderwick, H, Tallack C, Watt T (2019). What should be done to fix the crisis in social care. [online]  Available at [Accessed at 27 September 2021]


[5] HM Government (2012), caring for our future: reforming care and support. [online] Available at [Accessed at 12 July 2021]

[6] Peter Lilley (2021). Solving the social care dilemma? A responsible solution[online] Available at [Accessed at 26 May 2021]

[7] The Carer (2021) Care sector backlash at govt’s ‘lip service’ to care in queen’s speech. [online]  Available at [Accessed at 7 September 2021]

[8] Alderwick, H, Tallack C, Watt T (2019). What should be done to fix the crisis in social care. [online]  Available at [Accessed at 27 September 2021]

[9] HM Government (2012), caring for our future: reforming care and support. [online]  Available at [Accessed at 12 July 2021]

[10] Alderwick, H, Tallack C, Watt T (2019). What should be done to fix the crisis in social care. [online]  Available at [Accessed at 27 September 2021]

[11] Peter Lilley (2021). Solving the social care dilemma? A responsible solution[online]  Available at [Accessed at 26 May 2021]

[12] Farrah, M., (2022). Stats And Facts: UK Nursing, Social Care And Healthcare 2022. [online] Available at [Accessed 4 July 2021]

[13] Bunting, M., (2020) Labours of love. London: Granta Publications.

[14] Bottery, S., (2019). What's your problem, social care?. [online] Available at: [Accessed 18 October 2021].

[15] Thorlby, R., Starling, A., Broadbent, C. and Watt, T., 2019. What's the problem with social care, and why do we need to do better?. [online] Available at: [Accessed 6 October 2021].

[16] Glasby, J., Zhang, Y., Bennett, M. and Hall, P., 2020. A lost decade? A renewed case for adult social care reform in England. [online] Available at: [Accessed 4 October 2021].

[17] Health Org. (2021) Workforce projections. [online] Available at: [Accessed 16 September 2021].

[18] The Carer (2021). Sector backlash at Governments ‘lip service’ to care in queen’s speech. May/June 2021. Page 7

[19] Bottery, S., (2019). What's your problem, social care?. [online] Available at: [Accessed 18 October 2021].

[20] Bunting, M., (2020) Labours of love. London: Granta Publications

[21] Locke. M. (2021) Personal Communication

[22] BBC One, (2020). Sir Simon Stevens: Social care reform needed within a year. [video] Available at: [Accessed 20 September 2021].

[23] Bottery, S., (2019). What's your problem, social care?. [online] Available at: [Accessed 18 October 2021].

[24] Alderwick, H, Tallack C, Watt T (2019). What should be done to fix the crisis in social care. [online]  Available at [Accessed at 27 September 2021]

[25] Nix. S. (2021) Personal Communication

[26] Bottery, S., Varrow, M., Thorlby, R. and Wellings, D., 2022. A fork in the road: Next steps for social care funding reform. [online] Available at: [Accessed 8 August 2021].

[27] Bunting, M., (2020) Labours of love. London: Granta Publications

[28] Thorlby, R., Starling, A., Broadbent, C. and Watt, T., (2019). What's the problem with social care, and why do we need to do better?. [online] Available at: [Accessed 6 October 2021].

[30] Thorlby, R., Starling, A., Broadbent, C. and Watt, T., (2019). What's the problem with social care, and why do we need to do better?. [online] Available at: [Accessed 6 October 2021].

[31] Glasby, J., Zhang, Y., Bennett, M. and Hall, P., 2020. A lost decade? A renewed case for adult social care reform in England. [online] Available at: [Accessed 4 October 2021].

[32] Bunting, M., (2020) Labours of love. London: Granta Publications

[33] Locke. M. (2021) Personal Communication

[34] HM Government (2012), caring for our future: reforming care and support. [online] Available at [Accessed at 12 July 2021]

[35] Thomas, C., 2021. Home care postcode lottery: 80,000 care home residents could be receiving social care in their own homes. [online] Available at: [Accessed 11 November 2021].

[36] Hudson, B., 2021. 'Why don't they do something about it?' The politics of doing nothing | British Politics and Policy at LSE. [online] Available at: [Accessed 5 October 2021].

[37] ibid

[38] Hudson, B., 2021. 'Why don't they do something about it?' The politics of doing nothing | British Politics and Policy at LSE. [online] Available at: [Accessed 5 October 2021].

[39] O'Shea, D., 2019. Lack of social care costs the NHS £27,000 per hour. [online] Available at: [Accessed 27 September 2021].

[40] Bottery, S., 2019. What's your problem, social care?. [online] Available at: [Accessed 18 October 2021].

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