"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......
SOCIAL CARE REFORM - WHY IT CAN NO LONGER BE IGNORED
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% 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. 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 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. 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 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 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’. 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. 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. 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.
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 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. 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. 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 currently. In 2020 there was a 6.6% vacancy rate with a turnover rate of 33.8%, in comparison to the 2017 turnover rate of 27.8%. It is estimated that there will need to be 520,000 extra staff by the end of 2035 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”. 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. 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. 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. 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, 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. The proportion of staff being paid minimum wage has increased from 10% in 2016 to 30% in 2020. 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.
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. However, between 2010 and 2018 there was an 8% cut in social care 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% decrease in government spending for local authorities, significantly limiting their spending power. In total there as been a £216 million reduction 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. 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. 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. 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. 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. 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.
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’ 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 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’. 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 and this number will continue to rise and will not stop. 75,000 more beds will be needed by 2030 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.
