Social Care — Another Call for Change but is this one Different?
Labour recently announced a forthcoming manifesto pledge to create an elected upper chamber that would replace the current bloated House of Lords (HoL.) The commitment was said to be based on constitutional reform as part of a redistribution of power to deliver economic improvements. The idea is likely to be popular as much of the country struggles to see what the current upper house is for.
Within days of Labour’s announcement however, we saw an example of something practical and important in which the HoL is involved. After spending 10 months’ work gathering information from far and wide, the HoL Committee on Adult Social Care delivered its report. For many working in the beleaguered sector it was yet another document from the great and the good — but might this one actually make a difference? If so, might it also illustrate that the HoL can have a genuine purpose?
Well, it certainly didn’t hold back on its criticism of the Government or sugar coat its view of the sector’s multiple problems. It described the Government’s “crippling failure to sustainably invest”, right up to November’s Autumn Statement which included a commitment that “falls short of what was recommended to our Committee by Mr [Jeremy] Hunt himself only a few months ago” before Hunt became Chancellor.
Those at the sharp end are unlikely to be awash in reassurance. One of the most striking aspects of this debate is that it has been going on for decades. The 1997 Blair Labour Government promised to address the (then) serious issues but didn’t. The Dilnot Commission was set up by the Coalition Government in 2010 and its report was widely praised from all sides and yet the green papers and promises that resulted from it generated pretty much zero action. Just over a year ago, the ‘People at the Heart of Care’ white paper outlined a 10 year vision which the report describes as falling “sadly short of providing a concrete and fully resourced programme of change.” Even when, last year, the Johnson Government appeared to at last actually commit to do something, the action was set for October 2023 — and that has now been postponed for another two years. It’s a history of empty words and inaction from Governments of all colours. Meanwhile, the problems exacerbate and the impact becomes ever more foreboding.
One of the biggest hurdles in recognising the importance of social care, its problems and the need for solutions is that the term itself is often not understood by the public. Well, we should fix that right now. A quick glance at some headlines explains why –
· It’s very broad — “care” could mean anything from the day-to-day support of a disabled child to in-home or in-residential care for older adults. It is provided by carers who are both unpaid (often family) and paid.
· It’s not just something that happens to other people — 1 in 5 adults (around 10 million) in England either receive or provide care and we all have a 50% chance of becoming an unpaid carer by the age of 50.
· It won’t automatically be there for us when we need it — you may think that it is provided for free by the NHS because you have been paying via tax. It’s not, it isn’t and you haven’t.
· It’s a massive beast to manage and pay for — at c 1.6m, the adult social care workforce is bigger than that of the NHS (c 1.4m.) Given that imbalance and the scale of debate around NHS funding (£153 bn), how is it that we all seem so silent on the equivalent for social care (just £17.1 bn)?
The fact that much of this may well be news to many of us goes to prove that, as Jeremy Hunt himself put it, the invisibility of the sector is “deeply entrenched.” That’s a problem given that our own lives are very likely to be touched by it and that its troubles need to be fixed with public (our) money. In short, we need to know and care.
So, it’s big, invisible and nebulous but there’s another angle — it’s subject to the ticking time bomb of demography as our population becomes older. The problems that this will bring tomorrow will exacerbate those being dealt with today so we need a long term vision. It’s a global challenge too therefore that vision must include lessons learned from other countries. The HoL report references successful approaches made by Japan and Germany. I wrote about this international perspective in March 2020 -
The HoL report identifies a number of very important headline issues that are causing pain today and they represent a concise summary. They include –
· Responsibility and funding are messy and disparate. Local authorities are responsible for funding, planning and means testing adult social care although actual delivery is often via charity and commercial suppliers commissioned by them. Local authorities must largely raise the funding themselves via council tax etc with only limited support from central Government; despite increasing demand, local authority spending on adult social care per person is estimated to have reduced by 12% between 2010 and 2018. All of this has, in the words of the report, left “adult social care extremely exposed in recent years.”
· We are reliant on unpaid carers. Many of us become carers for loved ones who are disabled, whose lives are suddenly derailed (maybe by a stroke or dementia for instance) or maybe simply need help to cope. There is often little or no warning and the impact for the carer is dramatic in that they are faced with new costs (e.g. equipment such as wheelchairs, transport to hospitals, home adaptation costs etc) at the very time that their ability to work is curtailed. Without them, the state would need to spend an estimated £132 bn per year providing the services that they provide for free. The paper succinctly describes unpaid carers as “a national but neglected source of expertise, skills and knowledge.”
· Unpaid carers are badly supported. Because of the disparate range of services involved in providing support, unpaid carers must “contend with a baffling range of organisations” including NHS hospitals, local authority social services, independent care agencies, pharmacists, district nurses and mental health services etc. One carer said that “there must be many people who are overwhelmed by the ad hoc nature of adult social care and who find it almost impossible to navigate their way through the maze.” With the threshold for service qualification having regularly risen, there is also a concern that it is becoming harder to obtain support in the first place. Simple things like respite “short breaks” have a massive positive impact but are too rarely available and progress in funding initiatives to address this have been described as “too slow.”
· Unpaid carers are struggling and burning out. The consistent picture is of unpaid carers as “exhausted — physically, emotionally and financially.“ A significant contributor to this latter point is the “not fit for purpose” carers allowance which is thought to play a big part in the fact that 44% of adults who provide more than 35 hours of caring per week live in poverty.
· Paid carers are walking away. Whilst family ties obviously play a big part in the motivation of unpaid carers, the compassion that drives caring as a chosen occupation is being severely tested. Salaries, training, working conditions and recognition are all lacking. In October 2022 there were no less than 165,000 vacancies in the sector as home grown carers left and overseas carers were blocked by Brexit and other “constraining immigration rules.” This represents an eye watering turnover rate of almost 35% (up from 25.5% just 18 months ago.)
One overarching issue repeated throughout the report and likely to be a foundation for the above is the lack of centralised control and responsibility or “any suitable national long term plan” for it –
· In England there is no centralised care service, although in Scotland Parliament has committed to an operational National Care Service by 2026;
· England (as opposed to Scotland and Wales) has no workforce strategy equivalent to the NHS ‘People Plan’;
· Nowhere is there a Commissioner for Care & Support with centralised responsibility operating in the way that existing Commissioners for Children, Small Business and Information do.
Given the fragmentation of funding and operations (and the day-to-day problems that this causes in delivery) it is clear how difficult this would be to deliver — but equally how necessary it is.
A key part of any centralised planning will be better integration of social care provision with providers of related support — most notably, the NHS. The report here cites a bewildering array of “initiatives and mechanisms” going back more than 12 years (including the Integrated Care & Support Pioneers Programme and New Deal for Communities) and notes that “none have worked” largely because people see there always being “two pots of money” that prevent proper integration. The discharge of patients from hospital is just one much talked about example problem to be addressed because of its critical impact on limited bed availability. Housing is another one — there are far too few appropriate homes available or being built and the Disabled Facilities Grants (to enable homes to be adapted) is slow both in its application process and Councils’ commitment to deliver once approved. In both of these cases — and likely many others — the lack of integration clearly represents a dangerous obstacle.
Right now almost three quarters of healthcare leaders say that inadequate social care capacity has a significant impact on their ability to tackle today’s care backlog. With the turnover in staff, vast numbers of unfilled vacancies, strain of unpaid carers and the impact of an ageing population, this will inevitably become much worse.
There are some small signs of positives on the horizon. The report highlights the importance of the Government’s commitment to invest at least £150m in “caretech” innovation supporting preventative care and independent living through new digital technology. The Government has also recognised the importance of providing short breaks for unpaid carers and has committed £25m to supporting these and exploring other means of providing respite. Most importantly, the report recognises that new legislation (normally the recommendation of these reports and invariably the action that then grinds on interminably) is NOT necessary. The Care Act 2014 contains “many solutions” that could make a real difference if properly implemented and funded.
These limited glimmers of hope must be balanced against a Government too often seemingly in denial. Two new acts over the last 8 years (the Care Act 2014 and the Health & Care Act 2022) are cited by Ministers as evidence of action and yet the report finds that “tragically, very little has improved for those who depend upon or provide adult social care.” Jeremy Hunt considers that the situation has improved and credits part of the reason as the change of name from the Department of Heath to the Department of Health & Social Care. Make of that what you will.
In the last quarter of a century since Tony Blair pledged urgent action, far too little of any substance has been done by Governments of all colours. Blair made the pledge at the time because the situation was so dire then so where we are now should be a source of national shame.
The truth is however that many of us remain blissfully ignorant of the situation until it touches our own lives. Maybe that is one of the reasons politicians let it fester in favour of other issues more likely to be vote winners. It’s big, complex and expensive so they may find it attractive to ‘kick it into the long grass’ to be dealt with later — but we can’t afford to let them.
At the conclusion of its work in late November 2022, the HoL Committee wrote to Steve Barclay (Secretary of State) and Jeremy Hunt (Chancellor) with seven questions about the specifics of funding pledges for social care. Those in the sector desperately waiting for action will — on the basis of the past — not be holding their breath but if a worthwhile commitment of action can be gained then we should recognise the role of Lords and Baronesses in achieving it. And we should get behind them.
