The issues facing adult social care are well rehearsed. A lack of vision for the future of services, continual delays to system reform, reduced funding in the face of rising demand, with workforce recruitment and retention problems and increasing market fragility.
Despite the same old arguments, there is still no solution in sight, but the National Audit Office (NAO) has launched an investigation into overseeing and managing the adult social care market. As part of its research, the NAO and The MJ gathered local government experts to look at some of the issues facing local authorities.
Unsurprisingly, the problems have been exacerbated by COVID, with the already-fragile markets hit by a further double whammy of falling occupancy as people shun care homes and the rising cost of delivering care in a pandemic – even with the short-term COVID cash.
Our debate starts with the positives. ‘Visibility of the care sector is probably higher than ever in my career,’ one of our experts suggests. ‘We are closer to parity of esteem than we have been for years.’
Closer, perhaps, but full parity of esteem remains elusive. There are a host of reasons social care and the NHS are viewed differently – not least because people think health services are ‘free’ compared with the costly price of social care.
Despite a ‘rocky start’, the relationships and systems put in place to deal with COVID have created a better system, they suggest, and there are blocks to build on. But there are questions going forward.
How well does the care market meet the needs of care users? And is the market sustainable, particularly now families may be reluctant to ship their relatives off to care homes that suffered so badly during COVID?
One of our debaters suggests the ‘prize’ will be to keep the dialogue and ‘mutual understanding’ created between councils and care providers during COVID after we have got through the crisis.
Meanwhile central government has, during the pandemic, created a system of data collection from the market which gives a far clearer picture of what is going on. ‘Now it’s got that lever it won’t let go of it,’ we are told.
But one participant has a challenge: ‘Now you know all this what is the Government response going to be? We are telling you council tax is a regressive way to fund adult social care, what are you the Government going to do to change that?’
The Department of Health and Social Care (DHSC) is increasing its capacity, but that brings its own problems. Getting up to speed on the issues surrounding social care, while dealing with a crisis, is not an easy task.
‘Are we sure we need to do every single process in 152 different ways?’ one of our debaters asks. But there is a widespread belief that a national care service is not the answer.
‘Thirty years on from when community care reforms were announced, it feels like we are having to make the case all over again for why local authorities should be commissioning care,’ it is suggested. ‘People have very short memories...we forget the problems that were there that community care reform was there to solve.’
When care is provided locally, one debater reminds us, there are vast differences in the market from one place to the next, from the cost of delivery, of properties and the local workforce, to the size and shape of providers. And there are huge discrepancies in the fees paid by different local authorities – and the NHS – that don’t always reflect the different costs.
And costs are also rising. For some providers, insurance is set to go up by 500%, we are told – which equates to £50 per person per week. It’s not going to suddenly go back down post-COVID.
‘Anybody can start up a care business in the UK, and CQC [Care Quality Commission] comes in later,’ we are told. Which raises all sorts of questions of the quality of care in the interim – and what happens when they collapse.
Another debater adds: ‘There’s a huge amount of anxiety about business continuity, what will happen next year, and do we have the tools locally to intervene? Not just the financial firepower but the tools and the permissions to intervene in the market? The Care Act feels inadequate to that particular task, and the CQC doesn’t feel particularly adequate either.’
With a complex market, including lots of small players and massive variation across the country, oversight is an issue – and it will be different post-pandemic to what we have had over the past year. We are told: ‘It is better than it was before the collapse of Four Seasons, but it is not what it should be.’
CQC is also accused of being ‘absent’ in the role of shaping the market, which is becoming increasingly outdated. ‘The market is becoming less innovative, more traditional and therefore less adequate,’ we hear. ‘We won’t be able to get the workforce for the traditional market, even where we reshape it we don’t have enough people working in the traditional market.’ And that is before you consider the impact of Brexit.
Another participant suggests different groups – local authorities, providers, CQC, think-tanks – are all ‘too fractured’. ‘We need to bring that together…to be the next iteration of the market position, linked to the economic plan for the area.’
‘Social care needs an industry level priority for development that picks up the workforce points and the consumer protection points that will give the public confidence. Local government is the national leader of that.’
Despite the rising costs of care – one of our guests suggests their council now spends 67 pence in the pound for social care – we are still no closer to resolving funding issues. If anything, financing the pandemic takes us further away from a resolution.
‘We understand costs far better now but there is no mechanism for that transparency to be expressed locally,’ we are told. The pandemic has also led to a more ‘blended market’ of state- and self-funders. One debater suggests that has put a couple of thousand extra people on the council’s books.
‘It has had an impact on inflation in the market as well as built some confidence that the NHS will allow the council to act on its behalf,’ they suggest. ‘It will be interesting to see where that goes next year in legislative terms.’
There also seems to be a new found political support at a local level for investing in social care – particularly a recognition that we owe a debt of gratitude to the social care workforce, the COVID heroes, who have been dealt a raw deal in the past.
But is there enough political support at the national level to actually see through the reform needed to get social care back on track? Our debaters don’t think so.
One attendee says: ‘Care close to home, in small homely contexts, is what we’re trying to create.’
Part of the problem with the delays to the Social Care White Paper is that the NHS is now three years in to the NHS plan, while social care, public health and children’s services are left ‘out of sync’.
The pandemic has shifted things. ‘We have the elastic pulled back and we can ping forward quickly on the basis of the work we have done on COVID,’ we are told. But is the DHSC ready for reform? ‘No. The vision piece and the political piece isn’t there.’
Another debater adds: ‘The messages that came out of the Green Paper are still the right messages. The experience of the pandemic has reinforced our belief in the primacy of localism and place. It has reinforced our belief in targeted prevention…about how local government can work with its communities to target support.
That additional departmental capacity and change at a senior level means there is the possibility of a fresh debate, one of our optimistic debaters suggests. ‘It feels like we need to go and have that conversation. It won’t happen otherwise…There isn’t enough political skin in the game to make it happen.’
The reform social care needs most is funding. The social care precept is a short-term fix of sorts but is ‘intensifying the issues’, particularly for those authorities with a low council tax base.
After two single year spending reviews, there is a tendency to be constantly reactive – and to believe a multi-year settlement will solve all the issues. As one of our debaters says: ‘I understand the political reality, but is that a bit of a backward way to think about it…we should think about the care that needs to be delivered and then think about it. That’s the way it works in the NHS.’
‘Let’s hope there is a proper CSR [Comprehensive Spending Review] next autumn,’ it is suggested. The whole sector, with providers, should be reinforcing the vision of a ‘care close to home and connected to health’, joined up as a single system and with a strong emphasis on prevention.
‘Use the spending review, because that will be the only game in town,’ one participant says. ‘We are not going to have healthy social care without healthy local government, and we are not going to have healthy local government without healthy social care. Those issues have got to be addressed in tandem.’
But politically, social care has tripped up at least two political parties, and as one debater suggests: ‘We ought to remember that Margaret Thatcher wasn’t brought down by trying to reform Europe – she was brought down by trying to reform local government finance.’
James Bullion – Director of adult social services at Norfolk CC and president of ADASS
Iain MacBeath – Director of health and wellbeing, Bradford MBC
Paul Najsarek – Chief executive, Ealing LBC
Robin Tuddenham – Chief executive, Calderdale Council
Simon Williams – Director of social care improvement, LGA
Aileen Murphie – Director of MHCLG and local government, NAO
Vicky Davis – audit manager, NAO
Heather Jameson – Editor, The MJ