A few weeks ago I was asked to join a panel discussion on Times Radio about social care reform and why it was needed. Over the last 15 months I have regularly spoken on Times Radio about how our care home was coping with the pandemic. I’ve had time to reflect on first hand experience of managing and running a care home in these unprecedented times.
Everyone has been keen to hear about the truth behind what it really was like during the pandemic in a care home. Were the government to blame with the excessive deaths in care homes? Did we have enough PPE? Did Covid get into our home? These type of questions are easy to answer.
But in terms of the larger all encompassing subject of social care reform….. I don’t get asked about it. I know it is desperately needed, but I believe the possible solutions and the associated costs may be too difficult for the general public to digest and so perhaps this is why in the Queens Speech last month, despite promises by the current and previous Government, there was just 10 words given to social care reform.
The subject of social care reform struggles for public attention. Social care has a history of invisibility and complacency. The social care crisis is caught up in a repetitive loop of alarm alternating with apathy. There are well pulbicised care home scandals which lead to more regulation and inspection and rarely to increased funding. The public are used to hearing the bad stories of about life in a care home, these are repeated, but the wonderful stories of care are rarely shared. (Even the interviewer on the Times Radio panel interview even fell into this trap).
So what has the experience of owning a care home led me to my belief that social care reform is needed?
1. FEES - At the heart of this issue is the fact that there is a massive disparity between costs of care (and for the purposes of this article I refer to residential care). Local Authority funding is being squeezed to untenable levels, infact before writing this I was completing a spreadsheet to justify why I need an extra one percent increase on fees above the two percent increase granted by the local authority, to justify this extra one percent for two residents who we have not received any fee increase for in three years, I have to explain what I have done to reduce expenditure – they suggest redundancies and fund raising… We have always wanted to continue to charge the same for a self funder as a local authority placement, Sadly this is looking like it will become impossible as the Local Authorities can not pay realistic costs for placements . In the majority of homes that take both Local Authority placements and self funders, this is resulting in self funders (those who earn above the £23,000 threshold to receive local authority funding) “propping up” the industry.
2. STAFFING - Social Care staff are underpaid, undervalued and currently massively demoralized. Cost pressures on many homes mean staff are under pressure to perform more tasks leaving less time to actually “care”. I am currently looking for an additional carer to join our team. I had 5 applications, not one turned up for an interview. I am not alone. There is a massive shortage of carers (I believe the situation is the same in nursing). Coming out of a pandemic, those working in social care are tired and feel undervalued. The announcement about vaccinations being mandatory for those working in care homes did nothing to motivate an undervalued workforce. The reason being as follows; Anyone working in a care home must be vaccinated, carers, cleaners, people working in the kitchen, the same goes for all working in a care home even if not directly employed – hairdresser, plumber, electrician. All staff at our home are vaccinated, all agreed, some took a little longer to decide but everyone is vaccinated. However…. A nurse, paramedic, doctor currently does not have to be vaccinated. They can come into any care home with no requirement to (currently) be vaccinated. Double standards perhaps? In the case of any covid outbreak the Department of Health felt care staff did not require the same level of PPE as NHS staff – No full gowns and no enhanced masks.
3. PREMISES -Small privately owned homes are closing at a faster rate than other homes due to pressure on them to conform to unrealistic building requirements. Our care home is a home, in places a home which is over four hundred years old. Beams, wonky floors, individual rooms. The requirements for our building are increasing almost monthly and some just can not be met. As an example; we do not have any en-suite bedrooms, the majority of those we care for live with advanced dementia, many are incontinent and many are not mobile. En-suites would not in any way enhance their quality of life. I have been warned this may become a requirement for all care homes. To do this we would have to flatten our home as the drains would need to be entirely rebuilt. I am told that our exisiting quarry tiled hall may no longer be regarded as acceptable for infection control. I worry that the future of care homes may only be purpose built clinical, hotel style of homes which are soulless and in no way offer a “home from home” experience.
I was asked to speak on the panel interview regarding challenges within in a care home that provides care for “self funders” (those who have finances above the threshold to have care paid for by the local authority) and for those who are funded by the Local Authority. The weekly rate that we charge whether a self funder or a local authority placement is the same. I believe we are in the minority in this regard and the majority of care homes do not charge the same weekly fees for self funders and Local Authority placements
I had been asked to join the panel to talk about the issues in terms of funding of placements primarily but I was aware that this discussion could cover other areas of social care reform. So a few days before the interview I did some background research.
To put this issue into perspective, the following needs to be understood;
· In 2019/20 1.9 million people requested support from their council, over 100,000 more than in 2015/16
· Social care budgets have been cut by £8bn since 2010 with 1.4m people living without the care that they require.
· The Lancet reports that It is believed that the number of over 85’s requiring 24 hour care will double between 2020 and 2035.
· 22% fewer older people were able to access care in 2017 compared with 2010
· In 2010 – 2018 there was an 8% cut in social care budgets, accompanied with a reduction in beds as so many care homes were closing.
· 1 in 10 over 65’s are anticipated in having care costs in excess of £100K, often due to dementia.
· Local Authority savings have been made by tightening the criteria for care and holding down costs paid for residential and nursing placements - having the result of bringing down wages in real terms or closing homes.
· There are more than 100,000 vacancies for social care staff.
· Approximately 10% of care jobs are paid under the minimum wage
· In March 2017 suicide rates amongst social care staff were twice the national average – this was even before the pandemic.
· Public spending on adult social care is less than 1% of GDP in the UK
The future of the care workforce is bleak and is aging. The average age of a care worker is 47. Young people rarely aspire to work in care. Chronic low pay has led to high turnover and vacancy rates and every year nearly half of care workers leave their jobs. In March 2021 Rishi Sunak described Social care as a “problem” at the same time the department of Health and Social Care at the same time was launching a recruitment campaign… who wants to work for an industry that the Government openly regards as a “problem”?. Coming out of a pandemic, where care staff have been under enormous amounts of pressure watching ten of thousands die, who is going to want to work in “a problem”?
Care is not thought of as a highly skilled job. From an academic point of view to work in care, grades don’t matter. Empathy, compassion, kindness, strength (emotional and physical), energy, flexibility, teamwork are essential. There are very very very few people who I met in the last 30 years in my career (prior to working in social care) who I believe could do the job of a carer.
The fall in beds across care and nursing homes is undoubtly due in part because of lack of staff, as rates are driven down, and the national wage increases it becomes increasingly tough to for small homes to remain open.
So.. I did some research into the larger care home operators. In Madeline’s Bunting book “Crisis in Care” she explains that The number of care homes are growing significantly with an annual revenue of £16.9 billion. New homes are being built and overseas investors make up 80% of all new homes. The care home market is becoming dominated by large operators owned by private equity companies who are often loaded with large levels of debt which conceals the true costs. It has been widely reported that a number of large home groups have gone into administration over the last three years. The biggest care home company, HC one with 349 homes has and estimated £500 million in borrowing., It is part of a Cayman Islands based group of companies.
The financial times calculated in 2019 that the accounts for the four biggest care home companies running 900 homes between them with 55,000 residents had accumulated debt which required £40,000 per bed annually in interest charges alone. Complex financial instruments underly these operations where property assets are separated from running costs and then used as collateral to borrow money…. The result is deeply unstable.
In 2017 (before the pandemic) commercial analysts estimated that a third of the UK’s bed capacity in residential care was at risk of closing in the next five years. The surviving care homes may then be tempted to push prices up.
In terms of our care home, this gives me sleepless nights. We want to continue to offer care to those who need it, regardless of whether they are self-funders or LA funders. But the reality is that in the last four years we have had to fight tooth and nail to get any increase. This year we were awarded a 2% increase in fees, the last two years we had received no increase. Whereas fees had increased for self funders on average 3% per year. Although we have a stable workforce and in the last three years we have had two resignations, we find it increasingly difficult to attract new staff, despite paying competitively. Regulations increase and infection protection controls mean that the small period style home are becoming impossible to operate within the current guidelines. Our care home is a 400 year old building, with that come the inevitable maintenance issues. It’s charm is that it is a home not a purpose built hotel style care setting. I believe it is part of its appeal, but
I do not believe that the social care system is fit for purpose. Hight levels of care are unmet and there is a history of underfunding which has in turn driven down the wages and impacted the morale of care staff. In the majority of care homes which provide care to local authority funded and self funders there are massive differences in fees and local authority fee increases don’t even cover the wage increase.
So… what do I believe?
The majority of the general public currently accept that health is a fundamental human right which is state funded via taxation. I believe care is the same, as a society we need to accept this and in this respect Government needs to be open, honest and brave in explaining this. It is wholly unfair that the costs of care for someone living with cancer are met by the NHS but someone living with alzheimers has to fund their own care (apart from in very very extreme cases where continuing Health Care and therefore the NHS may fund the placement). There needs to be a lifetime cap on care costs for those living with dementia.
There needs to be transparency of funding to care homes, including transparency of financial structures behind care homes. There needs to be a reform of how means testing is conducted at the individual level.
Care workers should be recognised for the vital role which they fulfil and need to be upskilled to make the industry more appealing.
Additional funding needs to be ringfenced for care, funding can not just be used to reduce pressure on the NHS.
It has taken me many months to attempt to get these thoughts on paper. Social Care is clearly a massive issue for any Government. But the discussions need to start, the public needs to be made aware of this ticking time bomb. Every member of society has a need to understand the issue and take responsibility for, what I believe, is a social duty to fund this system which is on it’s knees.
The first step I believe is that a dialogue has to be begin between those at the grass routes of care and those who are able to shape policy. At the start of the pandemic I had a zoom call with our local MP to explain the challenges we were experiencing…. I did not hear back from him. I would have expected a call….. A few months later another MP was canvassing, he wanted to know what worried me – I asked him what his party would do in relation to Social Care. His answer “Integrate Social Care and Care Homes with the NHS”. “What does that mean?” I asked…. He could not answer, it’s the elephant in the room that no-one wants to address…… he took my details and said he would love to talk to me in more detail……. I am still waiting.
I am not suggesting that either of the MP’s I spoke to didn’t realise that a solution must be found but the continuous largely meaningless platitudes being trotted out by the Government is not addressing the grave problem. I truly believe that unless the matter is addressed urgently there will be needless human tragedy of biblical proportions.