Health and social care are in a most parlous state. The Government has made a last-minute winter dash to block book around 2,500 beds in care homes to tackle the urgent need for hospital discharges.
Last week ministers said they had found £200m in addition to the £500m allocated to social care in the Autumn Statement to pay for the short-term care placements in order to free up beds in the NHS.
But with around 13,000 medically fit people occupying hospital beds in England, and the Local Government Association (LGA) reiterating its message that £13bn in additional funding is needed to address social care pressures, it’s clear that the latest initiative is no more than a stop-gap.
And sector experts believe it is an approach that could build up problems within a system that is creaking ominously.
Health policy analyst and former Mayor of Surrey Heath BC, Roy Lilley, said in his blog that ‘discharging frail, deconditioned people who have been stranded in hospital for weeks, to a care home where they face the prospect of further deconditioning is simply… pushback’.
Hugh Alderwick is director of policy at the Health Foundation, an independent charity committed to improving health and healthcare for people in the UK. What does he see as the biggest challenges in social care? ‘Frankly, social care is on its knees’, he says. ‘We have lots of people going without the care they need. The system has really been discoloured by many years of political neglect and underfunding, which unfortunately, looks set to continue.’
He points out that when the pandemic hit, Government spending per person on social care was lower in real terms than in 2010 ‘and that means many people are going without care’, with a high number of unpaid carers filling the gaps. There are also big workforce shortages.
The Health Foundation looked at rates of poverty and deprivation among residential care workers in the few years before the pandemic. ‘We found that between 2017 and 2020, just over a quarter of residential care workers in the UK were living in or on the brink of poverty. About one in 10 experienced food insecurity.
‘So, you have these big problems with conditions of work and pay that is too low. If you stand back from this, you have a system that is pretty threadbare, in desperate need of funding and reform. Those are the big challenges.’
Part of the answer is to have more investment in the system so staff can be paid more, he believes. He points out it has been about 13 years since social care had a national workforce strategy.
He adds: ‘There are a bunch of policy measures the Government could think about, like a sector-specific minimum wage, and new standards for provider contracts. We need to look at it in the round. Single measures in isolation might have unintended consequences, so you really need to have a strategy for supporting and expanding the care workforce. Part of that is about international recruitment.’
Changes to immigration rules since Brexit have made international recruitment more challenging, and care workers were added to the shortage occupation list earlier last year. This means international workers can come to the UK if they earn more than about £20,000 a year. ‘But, if you look at what the Migration Advisory Committee has said to Government, the most important factor that’s behind most of the workforce problems in the system is the persistent underfunding of the sector by the Government.’
The most fundamental problems, Mr Alderwick believes, are with the design of the whole system, particularly the lack of protection much of the population has against care costs.
He says there is a risk the Government’s decision to delay implementation of a watered-down version of the Dilnot proposals for a cap on care costs by two years means the reforms will be ditched.
‘This is framed around affordability and the challenges surrounding public finances, but ultimately, this comes down to political choices. The social care reform is affordable. We’re one of the richest countries on Earth. It’s really disappointing about the cap delay.’
If it so desired, the Government could offer basic protection against lower level care needs for everybody, in his view. ‘But at the moment we’ve got this safety net system where care is only available to people with the highest needs and lowest means. So it’s a huge gap in our welfare state and an ongoing public policy failure, and one that has been prolonged by Government delaying the implementation of the cap.’
He calls the challenges facing Integrated Care Systems (ICSs) ‘really significant’, with major staff shortages in the NHS and social care, massive pressures on services, and health inequalities that are wide and growing.
‘I think we shouldn’t expect too much from the new ICSs on their own without bigger national policy support,’ he says. ‘We can learn from the mistakes of similar versions of ICSs. Limited involvement of local government and other community partners held back previous versions of ICSs.’
Local government funding allocations need to be reviewed in the round to make sure funding matches need and helps reduce inequalities, he believes.
In his view, without sufficient funding, and without a clear national strategy for reducing health inequalities, the new ICSs risk being set up to fail by national policy-makers.
‘These are huge challenges that we will take a long time to make progress on. Integrating services is not a quick fix. There’s only so much local leaders can do with the hand they’ve been dealt.’
