What future for adult social care?

eight-themesThirty years ago many people with disabilities, people with mental health needs, children who had behavioural or emotional problems, frail older people, were put in some form of institutional care. The 1980s was a period when many of these institutions were being closed down, and alternative ideas about social care were being developed. Then, as now, the political agenda was to cut costs but there was strong support also for the principles of community based support, particularly for people with severe disabilities, and also for more flexible home care to enable older people to stay in their own homes. Nowadays no one would choose to return to the institutionalisation of the past, but the alternatives that were put in place are in serious crisis, exacerbated by ‘austerity’ policies for the last 5 years.

In 1992 the NHS and Community Care Act brought about a significant shift in the way adult social care was delivered. It’s been described as a ‘mixed economy’ of care, because although most adult social care is now delivered by private enterprise, charities still provide some services, and local authorities have legal duties to assess people’s needs and fund care services when people are unable to pay for their own. Over a million people receive support through the adult social care services. It’s estimated that 9 million people (17% of the population) have a long term health condition or are disabled.

So the system works rather like this. In theory anyone can contact the adult social care team in the local authority to get an assessment about what kind of support is needed. From there, a social worker will work with the person and their family to agree what’s often called a ‘care package’ or a care plan – this might involve joining a local lunch club or other social support, organising carers to visit the home to help with washing, dressing or eating for example, or facilitating a move into more supported housing or residential care.  There may be some financial support with this from the local authority but only after means testing.

The reality is of course not so simple. Local authority teams are so stretched its very difficult to get a response except in a real crisis – in some areas waiting lists are up to a year. Usually the people involved are in considerable distress, and it’s hard for them to take in information about the different options available. Often services provided by charities for example have particular criteria because of the way they’re funded – so if you don’t fit the boxes you may not be able to get the help you need. There are an estimated 1.4 million full time unpaid carers supporting people with serious illnesses and disabilities. Finding out what’s actually available in your local area usually requires a PhD in research studies.

The last time there was a serious examination of adult social care (which all politicians agree is in crisis) was in 2011, and has largely been ignored. The not so radical proposals of the Dilnot Commission which tried to address the worst inequities of the current system were to:

  • Increase the means tested threshold to £100,000 for those needing residential care
  • Put a cap on costs so people only need to pay for the first chunk of their care.
  • The government should devote greater resources to the adult social care system

To implement these would have added 1.7 billion to the costs of care in England.

In Scotland recent legislation has implemented full integration of health and social care services under partnership arrangements in each area, and over half a billion pounds is being invested in developing services.

In England, over the last 5 years:

  • Public funding for social care has reduced by £4.6 billion
  • 400,000 fewer people receive publicly funded care services than 5 years ago
  • Cost savings have meant lower fees to service providers – reinforcing low pay, low skill levels and closure of service

It’s estimated that there are 1.6 million adults with ‘unmet social care needs’, and the number of people aged 90 and over has tripled in the last 30 years. Loneliness and social isolation are now recognised as major social problems which cause ill-health and increase mortality rates.

Since 2011 the phrase ‘austerity’ has been used to describe the government’s strategy to reduce the national debt following the world banking crisis. Apparently ‘what is austerity’ was the most googled phrase after George Osborne’s last budget. ‘Austerity’ doesn’t mean the post World War 2 ration books, shortages and lack of choices that we can’t even imagine today. These days ‘austerity’ is about cutting down on welfare spending and public services, so it doesn’t affect everyone, just those who are the most vulnerable and least able to protest. International comparisons suggest that spending on adult social care in the UK is relatively low and there is no evidence that any other advanced country has contemplated scaling back the provision of care to this level.

The public funding for adult social care services is so poor, it’s a constant miracle that the system works at all. However while there are shocking examples of poor care for the most vulnerable people, there are many many dedicated people who really do the work because of the profound satisfaction they get from helping others. Most carers working for domiciliary care agencies are on zero hour contracts and are paid very poorly. Wages in residential care homes are not much better but at least the staff have contracted hours of working.

What does ‘austerity’ look like here in Portsmouth? Not a very optimistic picture. In the last five years the council has found savings of £74.4 million, with many reductions in adult social care services.

  • Adult Social Care budget is now £68 million a year – out of total council spending of £207 million
  • £31 million savings has to be found during the next three years across local authority services
  • Residents were asked to pay a 2% increase in council tax to support adult social care – this will raise just £1.5million during 2016 – 17

Already care homes are beginning to charge higher rates for people who are self funding to subsidise the low rates paid by the local authority – this is more than likely to lead to differentials in service quality. A new home care provider in Portsmouth has recently bought the franchise to set up a high end domiciliary care service – minimum of one hour visits at £20 an hour, considerably higher than the local authority rate. Unless there is a major new political settlement about the shape of adult social care for the next 20 – 30 years, the likelihood is an increasingly US style service based on insurance, and a two or three tier service depending on ability to pay.