Reflections on the developments in adult social care over the past decade brings to mind Charles Dickens’ memorable opening lines of A Tale of Two Cities – "it was the best of times, it was the worst of times."
Austerity has without doubt cast a dark shadow on the sector, with local government bearing the brunt of public spending cuts - central government financial support to councils has fallen by £16bn between 2010 and 2020. Councils have generally prioritised social care over other important local services but even so social care budgets have fallen by over £6bn since 2010.
The impact on providers, the NHS and most important of all people who use services and their carers have been well documented for example in last year’s Home Truths report by the Nuffield Trust and the King’s Fund. Our population continues to age and younger people with disabilities are living longer too. The increasing complexity and acuity of their needs has created fresh challenges and hard choices – for the NHS as well as social care - about how we fund, organise and deliver services to meet these needs.
These have been tough years for care providers. In 2011 the collapse of Southern Cross, the country’s largest single care home provider, was a wake-up call about the risks of large scale failure in the provider sector that delivers over 90% of services. The precarious state of the home care market is near the top of many Director’s concerns – no-one should be surprised that waits for care packages at home is now the biggest single reason for delayed transfers of care from hospital.
The introduction of the national living wage was an important step forward but has added to cost pressures, especially after the recent HMRC ruling on sleep-in payments and is insufficient on its own to address the growing problems experienced in many parts of the country in recruiting and retaining good calibre care staff. In the last few years workforce has become as big a challenge as money and is linked intrinsically to the quality of care people experience.
Care Act a milestone measure
And the best of times? The 2014 Care Act was a milestone, the most comprehensive and ambitious overhaul of social care legislation since 1948 that consigned the 1948 National Assistance Act to the history books. The way that the government engaged with the sector and its stakeholders to ensure the passage of the new Care Act is a model of good practice in policy development that contrasts sharply with the controversy surrounding the 2012 Health and Social Care Act. Unfortunately the postponement of part 2 of the Act - that would have introduced a cap on care costs – meant a loss of vital momentum in this crucial area of reform.
In the meantime closer working between adult social care and the NHS has become even more important as we grapple with many shared challenges. As the National Audit Office has concluded, whilst integration is vital to the sustainability of both services, local ambitions are too often impeded by national barriers; and local government involvement in sustainability and transformation partnerships remains work in progress. It will be important to ensure that recent national tensions about the use of Better Care Fund money does not undermine local efforts to build good relationships and use the public pound to achieve better outcomes for local people.
Quality challenges increasing
The impact of these developments on the quality of services over the last decade is mixed. The inspection of social care services by the Care Quality Commission between 2014-2017 show that although 78% of inspected services are assessed as good, there is wide variation across the country. Only 2% of services are rated as outstanding and there is too much poor care. 2% of services are currently rated as inadequate, and 19% of services are rated as requires improvement and are struggling to improve. 38% of services were still rated as requiring improvement following re-inspection, and 5% of these services had deteriorated. Not all services that were originally rated as good maintain quality, with 26% receiving a lower rating after re-inspection.
These conclusions are reflected in rising levels of concern expressed by Directors in our budget survey this year - 78% report that more providers in their area are facing quality challenges now as a result of local authority savings, rising to 83% anticipating that this will be the case for the period 2018-2020.
From a ‘glass half full’ perspective, the fact that despite austerity nearly four in five adult social care services were rated ‘good’ and many others have improved is testament to the resilience and commitment of care staff working under significant and continuing pressures - frontline staff have continued to keep the show on the road. Nor should the reliance of the system on over 6 million unpaid carers be taken for granted. We should be even more concerned about the growing numbers of people who fall outside of the publicly funded system – an estimated 1.2 million older people have unmet needs, an increase of 18% since last year.
Long-term perspective needed
Looking forward, the last decade offers some important learning opportunities for the next. Three general elections, eight White Papers, Green Papers and other consultations have scarcely altered the dismal and deteriorating trajectory of the adult social care system. This suggests that the process of reform is as important as policy content and detail. Some recent initiatives have been helpful and welcome – the Better Care Fund, the social care precept and the extra £2bn announced in the Spring Budget. But all are essentially short term measures that fall far short of the extensive reforms that are needed to place social care on long term sustainable footing. The Government has recently confirmed its intention to produce a green paper by early summer next year. It cannot come a moment too soon.