Reduced funding, rising pressures, fewer people receiving care and greater unmet need for people with the lowest incomes – there is no doubt that the adult social care system in England is at breaking point.
Roll back 6 months and there was a clear path towards improving the public funding of adult social care. Additional funding was announced in 2015, and increased in 2016. It was a welcome investment, if not enough to keep up with cost rises estimated at 5% a year above inflation. In addition, the government announced a green paper to develop longer-term options for a sustainable system. Not a solution then, but at least a clear plan.
That all changed with the announcement of an election.
The Conservatives kept social care as a priority, and their manifesto promised to publicly fund a person’s care once their assets fell to £100k, raised from the current threshold of £23k. While there was initially no mention of a Dilnot-style cap on total lifetime spend, the Prime Minister later clarified that there would still be a cap, the size of which would need careful consultation. Again, the Conservatives offered a green paper on a long-term sustainable solution.
Following the election, the hung parliament means there is once again a lack of clarity over what happens next for social care. The only mention of social care in the Queen’s Speech was to ‘bring forward proposals for consultation’.
Meanwhile, the concerns intensify, but even these aren’t straight forward. The few national indicators that we have suggest that for those receiving publicly funded care, the quality of that care appears to be holding. The biggest concern is that the numbers of those still receiving care has fallen sharply, with 26% fewer adults receiving care from local authorities in 2014/15 than 2009/10.
There is then variation in people receiving access. The gap between care needed and care received is largest for people on low incomes, there is variation in the quality that is provided, and there are major concerns for the fragile state of the provider market.
The CQC report on the state of social care services confirms that most social care providers are delivering services that are good or outstanding, but there is clear variation and nearly one in five services need to improve. The biggest concerns are in safety, for which around a quarter of providers must improve. Encouragingly, providers perform better in terms of ‘caring’, suggesting the systemic safety issues are not due to unengaged staff.
The report also shows a trend towards larger nursing and residential homes. The number of homes has fallen faster than the number of beds since 2015, meaning the average size has increased. This is of particular concern as the CQC found that around one in three large homes were inadequate or required improvement, compared to one in 10 for small homes.
The CQC previously warned that the social care market was near a ‘tipping point’ in their 2015/16 State of Care report. Fears over the market are also apparent in the annual budget survey from the Association of Directors of Adult Social Services (ADASS), with 69% of councils affected by provider failure in the last 6 months. In many cases contracts have been ‘handed back’ by providers, in others the providers have ceased trading. While councils have often found alternative providers, thousands of people were affected.
The fragile market is in part due to the low payments local authorities are able to offer. The survey estimates that the average payment for home care is at £15.39 per hour, 8% below the advised minimum from the UK Homecare Association.
The survey also reconfirms that the additional investment announced for adult social care is insufficient to protect quality and access to services. Of particular concern is that the conditions attached to the investment mean that the funding is more likely to be spent on care for people aged 65 years and over, yet pressures on care for people under 65 years of age are growing at least as fast.
The problems are clear. Investment has improved, but is still insufficient. The model for funding is still seen by many as inadequate and unfair. Local authorities are still struggling to meet total cost pressures, once again planning to use reserves to cover total spending. But the future plan looks more uncertain than ever.
In light of these concerns, the Health Foundation is teaming up with The King’s Fund to run our own independent review of the issues. We will look at the potential alternatives for public funding, both palatable and controversial, to develop a set of sensible solutions for a sustainable social care service. There will be no silver bullet that satisfies everyone, but the current system satisfies few, if anyone. There will be a better way, we just need to find it.
Adam Roberts (@ADRoberts777) is Head of Economics at the Health Foundation