Do the words ‘social care’ make you feel bleak? In England, there has been a relentless drip of bad news about the state of social care provision: most recently evidence that hundreds of care workers leave jobs every week, making a workforce shortage worse, and compounding pressures on the mainly privately owned provider industry, that even the CQC described as being close to a ‘tipping point’.

It was probably the very visible impact of this funding crisis on the NHS – pressure on A&E departments, and delays in sending people home – that got through to government in the end. The spring budget unlocked an extra £2bn in the budget and, before the election was called a green paper on finding ‘sustainable’ funding options had been promised.

This extra money, welcome though it is, will not go far. Our own analysis of the social care funding gap and its impact on the local sustainability and transformation plans for health and care services (STP) showed that the gap for this year alone is likely to swallow up the £2bn, and be over £4bn by 2020/21. True, the extra money will reverse a declining trend and represent a growth rate of 2.3%, but as Ben Gershlick has calculated, we will barely be spending more than we did a decade ago on social care.

Policy makers tasked with the job of considering funding options for the green paper might be forgiven for feeling bleak about social care. One of the first problems they will have to get to grips with is the limitations of the data, particularly about the thousands of people who have fallen out of the publicly funded system in England, as Dr José-Luis Fernández at The London School of Economics and Political Science (LSE) explains. It is hard to see any solution that does not involve further increases in funding, particularly to support those who are least able to manage on their own. But the political appetite for raising taxes is likely to be limited, given the speed with which the government backed down over proposals to change National Insurance contributions.

Which brings us back to the other source of bleakness: how to persuade tax payers to invest in a service which is frequently portrayed in the media as poor quality, staffed by undervalued and low-paid workers, prone to lapses of neglect, a service which we may one day need, but none of us want to think about.

But our work at the Health Foundation suggests that improving the quality of social care is not a counsel of despair, even while a better long term solution is being developed. There are two resources already in place: the power of communities and the power of people working in social care settings, and both are being harnessed in a range of projects across the UK funded by the Health Foundation.

Altogether Better, a project in North Tyneside, is bringing volunteers into care homes, to work with residents, staff and other health and care professionals to enrich the lives of older people. The project’s director, Alyson McGregor, is inspired by the experience of her own father, who has dementia, and the joy that an activity like dancing can bring when all other memories have unravelled. And the joy lifts not just the older people, but the staff caring for them.

Unlocking the potential of people working in a generally undervalued service is at the heart of another project, known as PROSPER, based in Essex. A small scale project aimed at improving safety, which was funded by the Health Foundation, has been scaled up. What is striking is the hugely positive impact on staff, when encouraged to innovate and try out new ideas – including one project known as Pimp my zimmer. There is currently a real lack of improvement training on offer in the care home sector and no national or regional bodies ready to invest in this way in people working in care homes. This project shows what can be achieved when you do.

One of the other reasons for social care bleakness is the physical reality facing some of those needing care and the social care professionals who care for them. But innovation can be found here too: in North Cornwall, technology is being tried out to reduce pressure sores; in NHS Lanarkshire, staff are trying out new approaches to reduce and manage incontinence, promoting better health and reducing waste at the same time. New head mounted technology is being trialled in Eastbourne and Seaford Clinical Commissioning Group in Sussex to extend the reach of GPs, while barriers between social care and medical teams are being broken down and scaled up in Hampshire. We also know that better medical care in care homes is a proven way to reduce illness and hospital use

The great strength of social care, at its best, is the values that underlie it. A focus on mind as well as body, on quality of life, not just the presence or absence of a person in a hospital bed. Although recent experience may incline us to feel bleak about social care, it is these values which inspire hundreds of thousands of people to care every day, despite low pay. If these can be preserved, valued better across society, and built on, the future may be much brighter than we think. 

Further reading


Alastair Macdonald

I am a retired renal physician and currently an ethical advisor in a New Zealand public hospital. In 2018 our public health sevice will celebrate its 80th anniversary of its inception in 1938. We are proud to be first in the world in this regard!!

We too have problems in terms of sutainability and I have found your article very useful. I will also use the references for work that I am doing in NZ.

One constructive suggestion that I have that might need exploration is to consider the important role of effective communication and its importance in the genesis of non beneficial care( some might even call this waste!)

Every intervention is preceded by a conversation. The effectiveness of this conversation is impacted upon by "busyness" , the emotions that surround signficant decisions and the lack of communication skills in health professionals. All of these contribute to the lack of recognition of the point in a patient's disease trajectory where the emphasis of health management changes from curing to caring.

There are many examples where procedures are undertaken in circumstances where the increased mortality of such an intervention is not recognised. A good example is that of frailty ( and its lack of recognition ) and an associated increase in mortality and morbidity ) in the context of proposed surgery (1)

Other examples of a different kind address the issue of lack of recognition that a patient's end of life is nigh! This is an area that is difficult to describe briefly, however a recent paper suggested that signifcantly over 30% of health expenditure in this context was unlikely to provide any positive outcomes.(2) A certain amount of non- beneficial care is inevitable in these circumstances, however in response should the question be - "Could this be an area for some fruitful audit and research?"

Non beneficial interventions also occur in less severe clinical setting e.g. the use of arthroscopy which found that the outcomes in patients with osteoarthritis of the knee, after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure (3)

In conclusion I suggest that such a questioning approach complements the equally valuable work that is being done in other areas of enquiry. Our public health services should be viewed as a "national treasure" I am sure this sentiment is shared by you and your colleagues.

Finally I would sugget that the concept of "stewardship" be widely diseminated. This is a Moral concept that can be viewed as being one way of looking at our "Health Commons" Each society needs to define its values, having a strong viable health service is part of this "commons". We need wise investment in our limited resources.
Sustainability includes some of the things I have mentioned in this missive.
Thanks for the opportunity to comment. I will follow your collective progress with interest.

1) Too Frail for Surgery? Initial Results of a Large Multidisciplinary Prospective Study Examining Preoperative Variables Predictive of Poor Surgical Outcomes.
2) Non benefical treatments provided in hospital at the end of life, a systemic review on the exent of the problem. International Journal for quality in health care. International Jounral for quality in Health Care. 2016 1-14

Ian S. Rickard

Interesting. Thanks. I didn't know that an NZ publically funded, free at the point of use, NHS pre-dated the UK NHS.

This whole business, of how we intervene in challenging and complex situations and why, is a minefield. Building and maintaing trust and establishing authentic relationships, within the framework of professional boundaries, requires investment in skills that must be learned, maintained and monitored through what has become known as Supervision and Mentoring; though I accept that outcome research into the desirabily and effectiveness of Supervision and Mentoring is not readily available.

Whilst the social and economic science is, argably, thin for this too: investing in the promotion of honest, professional and compassionate communications and involvement in and around decision making in complex care might lead to a reduction in the inappropriate use of non beneficial intervention; and because benefit is diffcult to define and agree about, decisions could be mediated by informed, but disinterested, third parties; and mitigated by interventions that evidentially, will and do help a patient to get the best out of her or his situation.

Tough conversations about cost-ffective and cost benefit health care choices require, therefore, a culture of public discussion about these matters, generally in everyday life and not just at times of crisis, if we are going to shift family attitudes.

This approach, which could be backed by Medics and led by Nurses will also incurs costs, including the costs of research into outcome effectiveness; that's if we choose to eschew spending tax payer money on pursuing expensive but largely ineffective technical medical solutions.

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