How to address the long-running crisis in social care
The pandemic has exposed the divisions in our health and care systems.
On one hand is the NHS free at the point of use, on the other is social care a means-tested, income-based service.
This faultline is a source of inequity and unfairness and includes the most pernicious means test in the welfare state. How do we fix this, is a new National Care Service (NCS) the answer or should social care be merged into the NHS?
There needs to be a new settlement that places human dignity as the core value. But the Chancellors recent budget completely failed to mention social care, another omission to add to a long list of broken promises across all major UK parties. All are rightly angered by the derisory 1 per cent English pay offer to the NHS, but the offer to social care is nothing.
In 2010, Andy Burnham proposed a £20,000 compulsory levy on people’s estates. Conservatives dubbed it the ‘death tax’ and sunk it. The proposal for a cap on lifetime social care costs, to protect people was at the heart of Theresa May’s manifesto in 2017. The so-called “dementia” tax blew up her campaign. Boris Johnson’s approach centres on the vague promise “that no one is forced to sell their home to pay for care”. You will search in vain for detail.
In 2019, Labour promised to “provide free personal care for people over 65 who need help and invest an extra £8 billion into adult social care”. It pledged to end the use of zero-hours contracts for care workers, and ensure they are paid a real living wage”. In also proposed the creation of a separate National Care Service (NCS). This aimed to move towards national frameworks for greater public provision of social care with local planning and delivery remaining within local councils.
In Wales such frameworks would mean that an NCS could construct a system of national pay rates. This is currently not possible with 22 different employers and pay scales. It might also examine potential for national commissioning rates for care homes in Wales. Sorting out these issues would represent huge progress, although some argue it is not radical enough.
Plaid Cymru’s “Care Commission” has recommended the creation of a single, fully integrated “National Health and Care Service for Wales”. Plaid estimate it will require an extra £247 million in funding (although this seems modest). The unified system approach of Plaid would force integration. It would be taxpayer funded and provided on the basis of need, not ability to pay. By definition it would end the gross disparity between treatment and cost of contracting diseases such as cancer and dementia.
But is there appetite for more structural reform in a system already subjected to “57 varieties” of change programmes? Would social care be “lost” in the NHS and stripped of all local democratic accountability and how would you merge local government and health service pension schemes – one unfunded, the other fully funded? Above all else addressing equal pay and terms and conditions is a gargantuan task.
And what about delivery structures? As Cian Sion and Michael Trickey argue “any plan for reforming older adult care must address whether the current mixed economy is the way forward….and the challenges posed by having hundreds of employers and no single pay determining body”.
In Scotland the cost of providing free personal care (excluding nursing care) for older people in 2017/18 was £480.4 million. A social care tax in Wales could raise circa £300 million but is it possible to introduce it in the midst of an economic and public health crisis and with a devolved government hesitant to use its taxation powers?
Local authorities at the sharp end of austerity have employed “subsistence” contracting rates to cut costs. While some of the private sector providers genuinely care and invest in the sector, others like the infamous Southern Cross were ruthless opportunists. The outcomes of this are unmet need, unwarranted variation in access and performance and a care home sector whose financial position is parlous.
‘Lack of resources’
At the heart of social care crisis is not structures but a lack of resources. The explosion of aging demographics sits side by side with the growing blight of young adult mental health problems. Figures suggest that cases of dementia in Wales will rise from 48,100 in 2020 to 79,700 in 2040. In between are the myriad of pressing societal problems dealt with by social care departments
In Wales, cuts to social care are not of the scale seen in England and the passing of the Social Care and Wellbeing Act in 2014 a positive legislative outcome. Nonetheless the Welsh NHS now accounts for around 50 per cent of Welsh Government spending.
Alternatively, social care within local government has the distinction of being the least cut of services under local democratic control. It stands as a second-class auxiliary health service, left to the vagaries of market forces and cash-strapped local authorities.
A new funding settlement must start with the 2017 report by the Health Foundation “The Path to Sustainability”. This estimated that pressures on social care “will rise by around 4.1 per cent a year between 2015 and 2030/31, due to demography, chronic conditions and rising costs. This will require the social care budget to reach £2.3 billion by 2030/31 to match demand”. Currently Local authority gross spending on all older adult care was £837.2 million in 2018-19.
In terms of parity of esteem the NHS in Wales has its own Chief Executive while social care forms a small part of that directorate. While local health boards have a duty to plan and provide for secondary, primary, public health and community care their gaze fixes upon Tier One targets especially waiting times for treatment, ambulances, and cancer. For NHS management, secondary care is the premier division.
When it comes to NHS and social care workforce differences in when salaries as well as terms and conditions are enormous. Welsh Government as the core funder for public services treats the NHS and social care workforces very differently in multiple settings not least funding the Foundation Living Wage in the NHS. The social care workforce alternatively is underpaid, under-resourced and undervalued. Sorting this is the number one political imperative.
‘Parity of esteem’
There needs to be a new definition of value employed based on parity of esteem which extends out to wider society. More than a quarter of deaths linked to Covid-19 occurred in UK care homes.
We must never forget the scandal that care homes received coronavirus patients from NHS hospitals early in the crisis without being tested. Coronavirus completely exposed the inequities of care, but everyone in the system were already aware of these problems.
Options for future funding social are many. The admirable proposal by Gerry Holtham and Tegid Roberts to raise a levy on Welsh residents followed countries like Germany and Japan who have both introduced social insurance systems.
The task is enormous in Wales. Spending per head of the population over-65 fell by 9.6 per cent in real terms, from £1,058 to £956 per head between 2009–10 and 2018–19.
Within the social care the huge pressures of children and families competes with adult services over an inadequate pot of money. The “levelling up’ that social care requires is parity of esteem, investment and resources in line with the NHS.
Neither a National Social Care service with local delivery nor an integrated service with the NHS, is a magic fix. Like the road to hell, social care structural reform is paved with good intentions.
But as Professor Robert Hudson argues “instead of asking if the NHS can fix social care, we need to start with a different question: how can people be best supported to lead the lives they choose”?