I have been closely observing developments in Social Care for many years. I joined Healthwatch in 2013, and previously I was part of other Patient and Public Involvement organisations such as Community Health Councils (if you remember them) for nearly 30 years.
Over the years I have visited dozens of Residential and Nursing Care Homes and talked with hundreds of residents and staff. I have also spoken with many carers who give care in the home about their experiences, and to people on the receiving end of the care services about how they were feeling. In recent years I have also had personal experience with my Dad towards the end of his life.
I have spoken about these experiences with social care to many groups over the years, and I have often started the session with a simple question, “How many of you are looking forward to your first day in residential care?”. To date no-one has ever said yes to that question.
There are no consistent answers to the follow up question which is “Why not?”, people usually say something vague about independence and/or institutionalisation. This has worried me for some time, if Residential Care is not good enough for the rest of us why is it good enough for the people who are already in the system?
Why do so many commentators say social care is broken? What is going wrong?
There is no doubt that Social Care has become big business. Councils receive approximately 1.8 million requests for support per year, and roughly 890,000 people are receiving long term care at any one time. In 2018/19, total expenditure on social care by councils was £22.2 bn, a real terms increase of £426 m (2 per cent).
Roughly 1.5 million people work in social care. In 2019/20 there were an estimated 18,200 organisations involved in providing or organising adult social care in England, those services were being delivered in an estimated 38,000 establishments.
In 2019 there were an estimated 17,000 nursing and residential care homes in England, housing about 418,000 people. This is 4% of the total population aged 65 years and over, rising to 15% of those aged 85 or more. 167,000 people are receiving specialist dementia care in care homes – around 40% of the total care home population.
Most social care has been outsourced and is delivered by the Private and Independent Sectors. Care services are usually provided on a means tested basis and are funded by Local Authorities and/or CCGs.
I sometimes make a direct comparison with the NHS who see far more people, roughly 1 million patients every 36 hours, 90% of those in Primary Care. The NHS is funded from General Taxation and NI at about £135bn, and its services are free at the point of delivery with a few exceptions such as prescriptions and dentistry. The NHS workforce is of an equivalent size to social care, but they work out of far fewer premises.
With that comparison in mind I would like to offer some thoughts about why social care may be in crisis:
- Social Care is far more fragmented than the NHS. The challenges in terms of getting consistency and quality are perhaps greater than in health care
- Many services are required to deliver a workable profit to the owners and investors. This builds pressures into the system and possible tensions with best practice.
- Austerity measures have been squeezing Local Authority, and with that social care, funding for 10 years. The easiest ways to reduce costs for owners and managers include reducing the workforce and cutting training budgets
- More and more Care Home residents have greater and more complex needs, and the funding regimes have simply not been able to keep pace.
- The pressures in terms of numbers of service users and residents, complexity of conditions, and increased costs are making it more difficult to treat people as individuals.
- The funding pressures are impacting on providers’ ability to attract and retain workforce (the vacancy rate is 7.3% and turnover is 30.4%)
- Pay for social care staff is generally poor, and 24% of jobs are on zero hour contracts. This may well be linked to the absence of significant unionisation of the workforce
Last but far from least:
- The political cost of reducing funding for the NHS is far greater than the political cost of reducing funding for social care or Local Government. No-one will march in the streets or die on the barricades for social care!
The pandemic has emphasised the difficulties that social care is facing. The rampant inequalities that are being exposed present extraordinary difficulties, and the legacy of the pandemic in terms of stored up needs will be substantial and enduring.
Social care is not yet broken, the often heroic efforts of social care staff have seen to that, but the crisis is real and growing. Social care simply cannot wait for the recognition and the funding that goes with parity of esteem. The time is now.
Chris Bain 