1. Stabilise and sustain the current system
30 August 2019
There's no doubt that the system needs fundamental reform. But the immediate priority for government should be to keep existing adult social care services running – providing a basic safety net for both older and working-age adults with high care needs and low financial means.
This safety net is failing. Government spending on adult social care in England fell from an average of £346 per person in 2010/11 to £324 in 2017/18. This is far less than spending on publicly funded social care in Scotland (£446) and Wales (£424).
Spending reductions have affected access, with fewer people eligible for care. But they have also affected the ability of social care providers to deliver high quality services. The amount local authorities are able to pay towards somebody's care in care homes is less than it costs to provide it. Many social care providers are handing back their contracts. And some are going bankrupt. Four in five social care services are judged 'good' or 'outstanding' by the Care Quality Commission (CQC), but there are variations in quality between regions and type of services. The quality of care in nursing homes is the biggest concern for the CQC.
Meanwhile, social care faces a staffing crisis. There are an estimated 110,000 vacancies in adult social care – around one in ten social workers and one in eleven care workers. Although increases to the national minimum wage have raised the wages of the lowest paid, the proportion of staff being paid the minimum has increased from 10% in 2016 to around 30% now. Many staff are on zero-hours contracts, and turnover is high. Workforce issues affect both care quality and the people delivering it. The vast majority of staff in adult social care are women, which means that the impact of poor working conditions exacerbates gender inequalities. Nurses working in the NHS earn 7% more than those working in adult social care – a gap set to grow under the new NHS pay deal. This can create problems for recruitment in social care and is unlikely to be sustainable long-term.
And then there's the need to meet increasing demand for care. By 2023/24, social care spending would need to grow at around 3.6% a year just to keep pace with the needs of an ageing population and growing numbers of younger disabled adults.
Simply meeting these demand pressures, under current eligibility, would require £2.7bn additional government investment by 2023/24 (compared to the current estimated adult social care budget). Boosting staff pay (to grow at the same rate as the NHS) to improve recruitment and retention, and hopefully quality, means this figure would grow to £4.4bn in 2023/24, with £1.0bn needed in 2020/21 and £2.1bn in 2021/22. These amounts are compared to the current estimated adult social care baseline budget, which does not include winter pressures monies and the social care grant, neither of which are committed beyond 2020/21.
Increasing fees paid to social care providers for their services (in addition to any price increases to boost staff pay) would be another route to stabilising the sector – and may be needed in some areas to cope with any increases in access. Extra funding may also be needed in the short-term to support social care providers at risk of failure.
Stabilising the current system also depends on wider public policy decisions. Future immigration policy, for example, must be designed to support the recruitment of international workers that the social care system relies on. More than 90% of care workers earn below the proposed £30,000 salary threshold that could be required to obtain a visa after Brexit, and 8% of staff are of EU nationality and 10% of non-EU nationality.
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