Tackling the challenge of social care

Social care is being dis­fig­ured by a crazy paving of fault lines dri­ven by ris­ing demands, finan­cial con­straints and com­plex struc­tures that strad­dle state and pri­vate sup­port. The cost of wrap­ping our arms around the vul­ner­a­ble is ris­ing and experts believe an extra £7 bil­lion a year, on top of its annu­al £22.2‑billion gov­ern­ment fund­ing, is need­ed to sta­bilise a sec­tor that has been bad­ly dam­aged by the pan­dem­ic.

The plight of care homes, where the COVID death toll has been at its most con­cen­trat­ed, have become a totem of the malaise of social care. Prime min­is­ter Boris John­son has pledged to “fix the cri­sis in social care once and for all”, yet pro­vi­sion was con­spic­u­ous­ly absent in the chancellor’s March Bud­get and many feel it will take con­sid­er­able inge­nu­ity to ful­fil Johnson’s promise.

Social care does not lend itself to easy fix­es: 1.1 mil­lion peo­ple work in adult care, but they are propped by more than five mil­lion unpaid car­ers (they may receive a carer’s allowance) look­ing after fam­i­ly and loved ones. The finan­cial pro­file is also con­fused, with fam­i­lies pay­ing £10.7 bil­lion for a range of care and the sec­tor fea­tur­ing 25,000 pri­vate busi­ness­es. 

It is an are­na where low wages dom­i­nate; almost 30 per cent of the work­force move jobs each year and vacan­cies stand at 122,000 or 7.8 per cent com­pared to 2.8 per cent across all indus­tries in the UK, accord­ing to The King’s Fund think tank.

“Social care was in a bad state before the pan­dem­ic and it has been weak­ened fur­ther by it,” says Car­o­line Abra­hams, char­i­ty direc­tor at Age UK. “There is a huge work­force short­age and there’s arguably a cri­sis in con­fi­dence among the pub­lic about care homes.

“There are also sig­nif­i­cant num­bers of old peo­ple who are try­ing to man­age with­out the sup­port they need with basic things like eat­ing, drink­ing, tak­ing a show­er and get­ting dressed, and those peo­ple are more like­ly to fall or get ill and need NHS care. Social care is often por­trayed sim­ply as being about old­er peo­ple, but it is a much wider issue than that and half the spend goes on younger adults with com­plex care needs and dis­abil­i­ties.”

Complex care needs

Greg Allen, chief exec­u­tive of Future Care Cap­i­tal (FCC), an inde­pen­dent char­i­ty shap­ing the future of health and social care, adds: “The sec­tor con­sists of a patch­work of reg­u­la­tors, pol­i­cy­mak­ers, com­mis­sion­ers and providers. Peo­ple often think of social care as the elder­ly and frail in care homes, but it spans chil­dren, young peo­ple, peo­ple of work­ing age, and dis­abil­i­ties, and each facet faces dif­fer­ent chal­lenges.

“Suc­ces­sive gov­ern­ments and pol­i­cy­mak­ers haven’t found a solu­tion, but this gov­ern­ment and oth­ers that fol­low can­not ignore social care because it will implode as a sys­tem.”

FCC advo­cates a care covenant, sim­i­lar to the UK’s mil­i­tary covenant, which estab­lish­es mutu­al expec­ta­tions and respon­si­bil­i­ties of cit­i­zens and the state around care pro­vi­sion. It also wants to see more detailed research and data deployed to help design ser­vices that are tai­lored to evolv­ing demands.

“We need to raise the debate to look at this from dif­fer­ent angles and see it as a big­ger soci­etal issue,” says Allen, who has worked at board lev­el in the NHS. “The pan­dem­ic has opened the public’s eyes not only to the amaz­ing care deliv­ered in homes, but that social care is not just about care homes. Per­haps the pan­dem­ic is a cat­a­lyst for bet­ter under­stand­ing and devel­op­ing bet­ter options.”

Dan­ny Kruger, Con­ser­v­a­tive MP for Devizes, recent­ly peti­tioned health sec­re­tary Matt Han­cock to explore sys­tems used in Ger­many and Japan, which involve social insur­ance to spread costs, while pro­mot­ing new mod­els of care that com­pen­sat­ed fam­i­ly mem­bers who give up work to per­form care and fund semi-pro­fes­sion­al domi­cil­iary care work­ers drawn from the local com­mu­ni­ty.

A public conversation

Kruger’s cre­ative approach is echoed around health­care as pub­lic anger con­tin­ues to rise about the num­ber of fam­i­lies forced to sell their homes to pay for care. The government’s recent health­care white paper, address­ing some of the wider con­cerns, promis­es greater inte­grat­ed care at local lev­el and the use of tech­nol­o­gy to widen the range of at-home care options.

“The pan­dem­ic has made a lot of peo­ple realise that even if you’re real­ly respon­si­ble, and you do all the right things, stuff can hap­pen, which can hold your life below the water­line,” says Ani­ta Charlesworth, direc­tor of research at the Health Foun­da­tion, an inde­pen­dent char­i­ty.

“Lots of peo­ple assume the state will be there for them if any­thing hap­pens to them or a loved one, so it is a deep shock when peo­ple find out that is not always the case. We do need a big pub­lic con­ver­sa­tion about social care because we have not worked out what our indi­vid­ual respon­si­bil­i­ties are for those we love and where the state should be sup­port­ing us.”

The Health Foun­da­tion wants the gov­ern­ment to invest to sta­bilise the cur­rent sys­tem, improve access to care, pro­tect the pub­lic from ruinous costs and explore alter­na­tive rev­enue-rais­ing options.

Unmet need

“Invest­ing in social care has a very big price tag and often the polit­i­cal gain does­n’t look that great. It’s the right thing to do and it’s the long-term decent thing to do, but there’s often not a lot of short-term polit­i­cal mileage in it,” adds Charlesworth. 

“The real­i­ty is there is unmet need, a lot of providers are not sus­tain­able and care staff work under real­ly poor terms and con­di­tions, while indi­vid­u­als can be exposed to cat­a­stroph­ic costs. 

“I believe the gov­ern­ment will do some­thing because the down­side of not act­ing on an unam­bigu­ous and bold com­mit­ment would be very dif­fi­cult. The ques­tion is how wide or nar­row the sup­port pack­age will be. The con­cern is that if it is not big enough then more peo­ple will exist in the silent mis­ery of unmet need.”

Car­ers UK, a mem­ber­ship char­i­ty rep­re­sent­ing the one in eight adults who are unpaid car­ers, wants to see ambi­tious reform that includes legal rights for paid leave and flex­i­ble work­ing for car­ers along with greater gov­ern­ment recog­ni­tion of their role in social care.

“We have wait­ed years, more than a decade, for a plan for social care and the pan­dem­ic has high­light­ed that who­lescale change needs to hap­pen now if it is to be fit for pur­pose in the future,” says chief exec­u­tive Helen Walk­er. “The demand for for­mal care has increased. If we ignore social care for much longer, fam­i­lies’ lives will dete­ri­o­rate and the econ­o­my will feel the hit too.”

Age UK echoes the call for urgent social care reform. Abra­hams adds: “If we con­tin­ue as we are, then everyone’s expe­ri­ence of it will get worse, and we will get more scan­dals to do with poor care, and that will put extra pres­sure on the NHS when it can least afford it.

“I’m opti­mistic they’ll do some­thing, but I’m wor­ried they’ll do enough. If we’re going to get social care reform and refi­nanc­ing, then it requires the prime min­is­ter to exert his polit­i­cal pow­er over the Trea­sury.”