Well whoever would have guessed that social care was in complete disarray? With more than 40 years of privatisation, minimal transparency, accountability and oversight, ten years of austerity, deregulation, multiple providers and a profit motive – it’s not surprising.
All of us have ongoing contact with the NHS; it’s visible, it’s not stigmatising to use and it even has its own logo. But the only people who seem to be aware of social care are those of us who use it, care for others, are workers in it or are policy makers.
Too often the discussion focuses on the costs of older people going into residential and care homes. Professor Bob Hudson, who is a public policy academic, and knows more about social care than the current Cabinet combined, always challenges with the question “what do we mean by social care?” To me it’s about supporting people to live as full, as happy and as well as any of us can, regardless of their physical or mental condition.
The scandal of the number of deaths in care homes during the pandemic is one of the most shameful aspects of this crisis. However, this has happened across Europe and not just the UK. Covid-19 related deaths amongst social care staff have often been lost amongst the figures.
Even before the pandemic, the financial framework and structure of the care system, or should I say industry, was extremely fragile. Successive UK governments have held reviews and commissions, none of which have been implemented; it was thrown on the ‘too difficult to resolve pile’. Boris Johnson came into office with ‘a plan to fix social care for once and for all’. So how did it all go so wrong?
Over the years we have somehow conflated ‘care’ with ‘care homes’. We have moved into a position of thinking that care can be delivered only by paid staff within certain settings. Yet the majority of care happens within local communities, by unpaid family carers and friends, in informal settings, in people’s own homes and in communities.
The pandemic exposed that there are over 8000 home care providers, the vast majority of them independent, private providers. There is very little state-provided care. Ian Birrell, a financial journalist who writes mainly for the Financial Times, and who is himself a family carer, wrote an article ‘Old Money’ in May 2020, which is a devastating analysis of social care, and explains the financial shenanigans. “This is a sector that has been exploited by corporate giants, using offshore tax havens hidden behind opaque corporate structures. Lurking behind the provision of care homes lies the world of global finance, in which some of our most vulnerable citizens have become a source of profit for billionaire owners, hedge fund operators and private equity barons.” It is a chilling indictment.
But it isn’t just about care homes, an increasing and significant amount of demand (about 35% of adult care budgets) is for support of working age adults. Mortality rates have fallen and life expectancy has dramatically increased for many people with disabilities. Whilst this is rightly celebrated, their needs are increasingly neglected. One in four requests for social care support from local councils is refused. People are told they need less – when it is obvious that more support is needed. Because of austerity, local councils now operate rationing, but they refuse to admit it.
There are relatively few charities that provide residential and domiciliary care, as the costs are so high. I used to run a charity for people with learning disabilities that had a small residential home. It was impossible to keep the home properly staffed, pay the staff decent wages and give them good conditions, and provide a range of activities for residents on the rates we got from the local council. Charities are having a tough time at present, and those who do offer a care facility are having to rethink their models.
Historically care facilities were sometimes set up and made sense financially as the then benefit system eg Housing Benefit, or Supporting People allowances covered costs. But the multiple changes to benefit systems for people with disabilities, nearly always involve cuts. The disgraceful removal of the Independent Living Fund in 2015, which was established in 1988 as part of Care in the Community, meant a number of people lost their financial support to live independently.
There is a lot of talk of integration of health and social care, but they are two very different cultures and the last action either needs is (yet) another major reorganisation. The reality is that social care has been the subservient partner for many years. Remember a lot of the Covid-19 deaths in care homes were the direct result of discharging sick people from hospitals back into care settings. This was then made worse by not allowing people to be admitted from care homes so we could ‘Save the NHS’. Even the initial rebranding of NHS staff as heroes did not include social care staff, and the pathetic ‘Carer’ badge was offered by Matt Hancock (remember that)?
Social care is now responsible for well over half of most councils’ revenue budget. There has been a precept in the last few years to help support Adult Social Care. This is inadequate in most cases, and children’s social care is also vastly underfunded. Because the payments offered by local authorities are inadequate, a number of the larger private providers focus only on self-funders, who pay higher fees. This has resulted in a shift of provision from poorer areas, such as the North East of England, to wealthier ones.
Ironically a number of private care homes are closing now because their occupancy is too low to be financially viable. People are frightened of being admitted to care homes. People in most care homes in the North East of England can no longer have visits from their relatives and friends.
The Care Quality Commission (CQC) is the regulator of social care and openly publishes its reports on services, however its capacity is very stretched and the times between inspections are lengthening. Although the financial market and unit cost savings predicate towards larger homes, these have proved literally deadly where Covid-19 is concerned. Some of the largest care home chains have the worst records of safety, when inspected by the CQC.
There is a political imperative to have hard discussions on tax and to act accordingly. One of the consequences of Brexit will be the loss of many care workers, particularly in the London area. Care workers working for different employers were identified in the early months of Covid-19, as one of the sources of the disease spreading so quickly among vulnerable people. The low wages for caring mean that Care workers often have multiple jobs and work many hours to get reasonable wages. They had very poor access to PPE in the early days with many workers receiving minimal protection and being told to make a paper mask last all morning.
So where do we go from here as the current system is clearly unsustainable, irreparable and inadequate? It is a complex and poorly understood sector, but vital to our social infrastructure. We cannot and should not throw money at huge private enterprises, nor will nationalising the whole system work. Local authorities must be given more funding, powers, commission more intelligently and run more services directly. People who wish to live independently or with families and friends should be properly supported to do so. Family carers should be properly recompensed with significant respite and back-up services. We need to focus on more community-based, not-for-profit and cooperative models of care.
Social care should be about meeting the needs of people as best we can; not reducing personal interactions to financially viable, fully costed impersonal transactions. People are not cost units.
We need to get back to values and principles and think about care. The Women’s Budget Group has just produced a report on ‘The Caring Economy’. That looks like a good place to start.