30 July 2019
Dr Gillian Dalley
The ‘problem of social care’ is currently perceived to be a problem of funding. As such, the funding question dominates policy-thinking and public debate. The central concern of this article, however, is broader. It focuses on the essential nature of social care, particularly its structure, quality and sectoral location – in addition to funding.
Key points about current social care:
- Social care is almost entirely provided by the private sector, for profit.
- Private provision means the whim of the market determines distribution, type and quality. This results in patchy distribution, flourishing in some wealthy areas, shortages in others, with widespread evidence of unmet needs, poor quality of care and lamentable employment conditions.
- Unlike care and treatment in the NHS, social care is not free at the point of use. Individuals requiring social care (as noted, almost all privately provided), are means tested. Those with assets over £23,250 are disqualified from receiving it free.
This submission argues the case for bringing social care into the public sector to remedy these failings.
The case for taking social care into public control:
Social care must be a service which is available to all citizens, based on individual needs, in settings of their choice. The ethos of public service – of fairness and high standards (for both service users and the workforce which provides the service) – should be at its heart. To achieve this, and as an essential public service, it has to be located within the public sector, just like the NHS. The notion of profit is alien to this vision and should be ruled out entirely.
- The vision can only be put into effect with major structural change.
- Currently most social care (around 90%) is in the hands of private providers (residential care homes – provided by private companies or a very small number of charities; domiciliary (home) care – provided by private agencies).
- Private providers range from small, single (often family) owner businesses to large companies often owned by hedge funds. Many have recently gone out of business, causing major problems for clients and local councils who have a legal duty to ensure those with eligible needs receive the care for which they qualify.
- Councils themselves, for the most part, are no longer service providers.
- Care services for individuals needing care are either a) commissioned and paid for by local councils or b) selected and paid for by individuals who don’t pass the means test (self-funders).
- The distribution of provision is highly variable geographically with huge financial implications for councils: in some council areas over 50% of clients are self-funding, with councils financially responsible for the remaining proportion; in others, fewer than 10% are self-funding, with councils financially responsible for up to 90% of those with care needs in their areas. Thus there is a ‘post code lottery’ in access and cost for both individuals and councils.
- In the future, the aim instead should be to achieve public sector provision consisting of a mix of residential and nursing care homes, home care, village living with a mix of facilities, access to which becomes available as individuals’ care needs increase – and other innovative schemes which may come along. Provision should be developed as needed, shaped by forward planning based on a continuous analysis of demographic trends.
- As long as councils retain statutory responsibility for social care, central government must guarantee adequate funding, thus ending the way in which it can currently squeeze local government at whim to the extent where councils can no longer fulfil their legal obligations to their residents. ‘A contract of care’ between government and people is required.
- Alternatively, radical change might foresee a funding system not unlike that for the NHS with a transfer from local to national funding.
3. Responsibility for planning:
Too often the development of social care is left to ‘happenstance’ and calculations about business opportunities as framed by businesses in the private sector. Private developers whose main goal is profit go where the money is – areas where wealthy self-funders are located, rather than poorer, council-supported clients – and not according to need.
Conversely, in other less wealthy areas, private companies are closing down care homes and home-care services haphazardly without consultation or thought to the welfare of clients, claiming their businesses are unsustainable. It is impossible under central government-imposed austerity for local councils to cope with growing levels of unmet need and demand.
4. Planning in the future:
A central requirement for any public service is that it meets public needs effectively, efficiently and economically, taking account of change in the short- and long-term. This requires planning, monitoring and regular review by the statutory services, locally and nationally. Planning must be undertaken for:
- workforce development, matching staffing to needs
- assessing and forecasting care needs over time
- designing and commissioning provision of appropriate accommodation (care homes, community buildings, resource hubs) according to changing demographic trends.
Such planning currently does not exist.
5. The need for quality improvement in the social care sector:
- Recent evidence has shown how appalling standards of care in the sector can be, along with widespread shortage of services, non-existent in some areas.
- Across the sector little training is available, with unqualified staff taking on huge responsibilities for which they are not trained. Few quality standards are laid down for the training required – either in care or management - leading to a downward spiral in quality. A comprehensive training programme must be developed.
- No serious investment in training from private providers is evident. Comparison with the NHS in relation to these issues is laughable.
- Regulation, in the hands of Care Quality Commission (CQC), is inadequate. CQC standards are not sufficiently explicit, being grouped under global categories such as ‘safety’ which are so broad as to be meaningless, and reports by inspectors are full of stock phrases and organisational jargon, which serve to demonstrate a lack of insight and responsiveness to the particular circumstances of individuals and their needs.
- At worst, inspections are infrequent and superficial.
6. Funding – current and future:
With the elimination of private provision, social care can – and must – be properly planned, costed, funded and provided – and all these functions aligned for maximum quality and efficiency. Issues include:
- Who pays? Currently individuals with assets above £23,250 have to pay for their social care. Otherwise it is state-funded via councils.
- Options are: a) fully funded from the public purse (either direct from the Treasury via national insurance/general taxation; or wholly via local councils;) or b) partially publicly funded, with citizens subjected to various levels of means-testing and/or capping.
Several reports have been published over the past 25 years, all accepting the notion of partial funding. Most reports accepted this with various suggestions of introducing caps upon the total amount any individual should be required to pay. The Dilnot report suggested the most ‘generous’(to the individual) level of the cap (£35k).
Only the Royal Commission report in 1999 suggested, in the case of residential care, the idea of splitting off the costs of accommodation and other ‘hotel’ services (meals, laundry etc) from the costs of the care itself with the former being means tested and the latter fully funded. This already happens in Scotland. This could be considered by government as an alternative to the full-funding of all aspects of the service.
7. NHS and Social Care - an integrated service?
Bringing social care into the public sector will be a major step in the journey towards possible integration of the two services. Ultimately however the source of funding needs to be better aligned. As long as social care is funded through councils, the division between the two will remain insurmountable. In times of pressure or crisis each service will always close ranks to protect its own interests (financial, professional, management). This is a fundamental, evidenced and incontestable feature of organisations and will always be antithetical to achieving the long and widely held ambition of integration.
This article is adapted from a submission to the Labour Party’s consultation on the future of health and social care. The submission was written by Dr Gillian Dalley – a Labour Party member in Islington North. The full submission can be found here.