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If the funding and provision of adult social care, the access to it, its quality and safety, and crucially the staffing are inadequate, this has serious consequences.
It leaves older or disabled adults without the personal care and support they need to retain independence and control, to remain in their own homes or stay out of hospital, or to access long-term residential care when they need it.
It places an ever greater burden on the millions of unpaid carers (often older people themselves) who we know too often have to support them unaided at detriment to their own health or ability to work.
It leads to avoidable harms and complications and to hospitalisation or lengthy delays in discharge back out of hospital.
Getting social care wrong is a lose-lose situation. And despite fantastic work done by individuals and organisations within the sector, it has been going wrong for several years, with no solution in sight.
A failure to provide sustainable and adequate funding for social care leaves the companies running care homes and home care agencies in a precarious position.
Most of all, with no workforce to deliver care, there is no viable adult social care system. It is a people business and neither artificial intelligence, telecare nor robots are yet ready to take its place – if they ever would be.
The National Audit Office report published this month – ‘Reforming Adult Social Care in England’ – painted a bleak picture of inaction and delay.
Government pledges to create new training places for social care workers and support training for skills had yet to be enacted, as had proposals to develop a more formal career structure.
At least two dozen councils told the NAO that they would be unable to meet the long-term care needs of their local adult population by next spring.
Despite an additional £265 million being allocated for the years 2022-24 in the Government’s plan, the NAO found that so far only £19.7 million had been spent, partly because the Department of Health and Social Care lacked the staff to administer the training and workforce development plan after its own recruitment freezes.
The NAO report came only months after a report – ‘The State of the Adult Social Care Workforce in England’ – by social care planning body Skills for Care, which found that around 150,000 social care vacancies (around 10% of the workforce) were unfilled, with around one-third of the workforce leaving within one year, and average hourly pay rates of only £10.11 for social care workers employed by private contractors.
Skills for Care estimated that, even without widening access to social care for people who need it, demographic change would require an additional 440,000 roles by 2035.
The report identified five factors that could reduce attrition and improve retention: being paid more than the minimum wage; not being on a zero-hours contract; being able to work full time; being able to access training; having a recent qualification.
Having all of these conditions in place could reduce turnover rates from 48.7% to 20.6%. But currently many workers enjoyed few of the five.
There had been a major upturn in international recruitment to the sector in 2023, though insufficient to compensate for the numbers of existing staff leaving.
Unison has described migrant workers in care homes who experiencing conditions “verging on modern slavery”, but who cannot leave their job because employers say they must repay relocation and training costs running into thousands of pounds.
Last year, a Migration Advisory Committee report on adult social care and immigration had highlighted the current reliance on overseas workers and the use of health and care visas for shortage occupations but highlighted the risk of exploitation, poor wages, and poor training.
Meanwhile, Boris Johnson’s 2019 election victory pledge to find “fix the crisis in social care once and for all, with a plan” was not reflected 657 days later in his Government’s 2021 Queen’s Speech.
The speech set out plans for an additional £33 billion over three years to be raised by a “levy” in the form of national insurance increases on working adults. But most of the cash was to be given to the NHS, leaving only £1.7 billion a year to social care. Much of this sum would be swallowed up in protecting people whose assets exceeded the £86,000 cap on individual care costs, rather than widening access to social care for others in need.
Even this commitment was then reversed. And choosing the instrument of a flat national insurance rate rise was rightly criticised as inequitable – targeting only those in paid employment, not taxing wealth or assets or those of retirement age and hitting those on lower income proportionately harder.
Nor is the current method of fundraising for social care equitable or progressive. Councils raise income from council tax based on property values and from business rates, so more affluent and thriving areas are able to raise more money, even though population deprivation and need are often lower. And even if they add an additional ‘precept’ on the council tax, more money will be raised in wealthier areas.
Councils also rely on central government support grants. But the Institute for Fiscal Studies has found that more deprived areas have been hit hardest by cuts to those grants, despite ‘levelling up’ pledges.
Economic modelling by independent charity, the Health Foundation, in 2021 suggested that, by 2030, adult social care in England would need an annual uplift of £8.9 billion (€10.3 billion; $10.7 billion) just to maintain current levels of service and £14.4 billion to restore access to historic levels. Social care access is already heavily rationed by strict eligibility thresholds and means testing, unlike free-at-the-point-of-use, needs-based NHS care.
These problems go back several years though.
The 2010-2015 Coalition Government’s austerity policy led to major cuts in local government funding and hence to adult social care budgets. And despite episodic short-term cash injections from ministers since then, those cuts were never adequately addressed, even as the population aged and need for care grew.
Independent think tanks The King’s Fund and Nuffield Trust estimated in 2015 that around 500,000 fewer people were in receipt of social care than in 2010.
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The 2010 election killed off Labour’s proposal for a cross-party consensus on social care funding and was lambasted by the right as a “death tax”.
The 2011 Dilnot Commission made reasonable recommendations, the implementation of which was killed off by the 2015 Conservative Government.
The 2014 Care Act was a well-regarded piece of legislation setting out standard entitlements and protections around assessment, support and care eligibility but did not come with the funding to support its implementation.
Theresa May’s hasty, poorly pitched or risk-assessed proposals of 2017 were shouted down as a “dementia tax” and disappeared from sight.
Brexit damaged the social care labour market.
Points-based immigration rules damaged it further. Although they eventually had to be relaxed to allow more immigrant workers in, lower-paid workers including those in social care were not initially included in the shortage occupation or skilled workers visa eligibility list, with predictable consequences.
UK workers are not lining up for such poorly paid, demanding and safety critical work.
And with labour shortages across many sectors, including the NHS, social care is in a competition to recruit and retain staff.
Labour had a part to play, before the 2010 election, in not planning sufficiently for the future funding and provision of social care and development of the workforce. And Shadow Health and Social Care Secretary Wes Streeting’s recent Conference speech contained little to suggest that the party has an adequate plan now.
The current crisis, however, is largely down to the Conservative-led Government of the past 13 years – either ducking key policy decisions, back-tracking on them, or enacting policy that actively damaged the capacity in the sector.
David Oliver has been an NHS acute hospital doctor for 34 years, looked after a Coronavirus ward throughout the pandemic waves, and has held a variety of medical leadership and policy roles. He is a regular columnist for the British Medical Journal