England & Wales Health and social care

Six things the social care green paper must address


Photo Credit: Alex E. Proimos via Compfight cc

It’s a New Year and our still sort of new government is still promising to address the social care crisis with a green paper that may be late and – if hope fails to triumph over experience – too little.

It’s not hyberbole to say that the social care system is on the brink of collapse. Without a doubt the system is not working for anyone, not for institutions, not for private sector providers, not for care workers and certainly not for those who need care or their families. Some signs of the coming crisis:

  • Rising demand: there are already over a million people in the UK with unmet care needs against the backdrop of rising numbers of older people as a percentage of the population.
  • Provider failure: care companies are going out of business at an increasing rate. Research from LGiU and the Association of Directors of Adult Social Services (ADASS) indicates that provider failure rates are doubling. This can mean costly intervention as well as personal misery in terms of people’s care being disrupted or individuals being overlooked and serious health consequences when frail and elderly people are moved from residential care.
  • Delayed discharge from hospital, pejoratively called ‘bedblocking’ – too many older people who could have been discharged are staying in hospital because of the lack of appropriate support at home or a place in a residential or nursing care. There has been a 130% increase over the past four years, with worse to come. The winter of 2017/2018 is ‘predicted to be worst ever’, which puts increasing pressure on an already creaking NHS cold weather service.

While there is no doubt that additional monies are required, even if funding shortfalls were bridged this would not ‘fix’ the system. Generally speaking, there is a wide degree of consensus around most ‘solutions’ to the social care problem, but there is little agreement, or support, on implementation.

  1. Service innovation and practice improvement

There is much agreement and some activity around service innovation and practice improvement. A number of places are experimenting with social innovation and practice improvement, particularly around developing multi-disciplinary and self-directing teams. Other areas are experimenting with new ways of involving volunteers and families to provide networks of care. And still further with outcomes based commissioning. But there is little consistency across the system or sufficient research into what works in practice improvement and implementation. There is also huge scope for the involvement of digital and the integration of data, but for structural and cultural reasons this continues to stall. For example

There needs to be better support for innovation as well as proper evaluation of outcomes and the ability to disseminate and implement better practice.

2. Funding and self-funding

The Local Government Association (LGA) estimates that over a billion pounds is necessary simply to shore up the independent care market. The adult social care precept, while somewhat helpful, did not bridge the funding gap. And perhaps no proposed amount of money can, given the amount of unaddressed need. Social care budgets, while no longer growing, are crowding out the other necessary work of local government.

More worrying than the funding gap for those who qualify for state support is the self-funding gap. Currently there are no financial products to help people plan for and pay for care. There is interest from the financial services industry, but there is insufficient policy stability for them to enter the market. The rejected Dilnot cap and the lack of clarity around spending gaps in the 2017 Conservative manifesto means that no one is able to compute liabilities with any actuarial certainty.

3. Incentivising integration

Everyone agrees that social care and the NHS need to work more closely together to support individuals with their health and social care needs and particularly during the transition between health and social care systems. A number of funds and schemes have been attempted to achieve integration, but these have all had mixed success at best. Worst still, a lack of stability or forward funding means that integrated teams are set at each other as Delayed Transfers of Care targets aren’t met and Better Care Funds are arbitrarily withdrawn.

There is no consensus on what integration should look like. While Labour has particularly focused on developing a national care service, this may not actually achieve integration. Either care would be subsumed to acute health needs or two behemoth institutions would be at each others’ throats and we’d lose the important local connection of providing care in a very local system that can access community assets and support a network of care around individuals.

4. Regulatory regime

Currently there is little to no regulation of the services provided by social care departments in the UK. There is some self regulation through professional bodies and some oversight by Department of Health, but currently only independent services are regulated by the Care Quality Commission (CQC).

While the LGiU would never advocate a heavy regulatory regime for local government, there is perhaps some greater need for supporting more self-regulation and the transfer of knowledge of best practice. Additionally, some councils are struggling with effective commissioning practices and oversight/cultivation of the care market, partly because of capacity and skill and partly because of the parlous state of the market. There is need for greater support for helping councils to identify where they are missing market management opportunities and how to achieve the skill set and capacity to do so.

5. Career of esteem

LGiU and many others have identified that part of the problem with social care is the intense churn of workers (about 30% turnover rate – which is about 4 times more than other jobs). There is a little pathway for career progression and not enough

Care workers are overworked, underpaid and still being paid less than the legal minimum wage. They are undertrained and allowed little discretion even when they are skilled and well-trained. They are the ones caring for people and often know far better than a potentially out-of-date care plan what needs to be done. We need to be able to harness the skill and aptitude of good care workers, so that we need fewer mediocre ones.

6. Support for carers

Without the ability to plan for or insure against the need for care, many people are finding themselves in the position where there is no money to provide care for a partner or relative, but no state aid either. Many feel forced to leave the labour market, often against their will and certainly against their interests. Any comprehensive care reform must include economic support for carers, either though a carers’ working tax credit or other means.

If there is to be any real reform in adult social care, these are the six key areas which must be addressed.

Read more about adult social care and localism in the recent LGiU publication: Reviving Localism: Three challenges.