For those who follow social care, the findings of our report will not, alas, come as a shock. Pressurised local authorities have reframed their role as providing a safety net for the most in need, and, for everyone else, they offer information and signposting to what's in 'the community'. Social care for older people: home truths shows that social care providers are turning away from local authority fees where they can, or cross-subsidising from the private payers, or just giving up completely. The policy of 'keeping people at home' is being undermined by an even greater workforce shortage facing home care providers, and patchy community health services.
For sure, there were real glimmers of innovation and good practice, driven by genuine collaboration between health and social care, and a gutsy voluntary sector determined to keep services going. And the Care Quality Commission, which has shone its increasingly bright light into social care, has also found that high-quality care can and does thrive across the country.
But we also found much pessimism about the future and a tendency for local authorities and the NHS to retreat to their respective moral high grounds. Local authorities are frustrated that the big money flows to the NHS – especially hospitals – who often get bailed out and don’t really know the painful discipline of balancing budgets. And the NHS – again, especially hospitals – are equally frustrated: they can't ever shut their doors, and feel they are the only part of the system that picks up the pieces when social care unravels.
In the middle of all of this is a bewildered public. A few years ago, a shadow minister for health – someone who had pushed hard for social care reform – remarked to me: “what really puzzles me is that this system is so broken and so manifestly poor, and yet my mailbag is not full of outraged constituents about this subject: they just don't write!”
Once a family is confronted by the irreversible, failing health of a loved one, their world is turned upside down. However well you think you might know the system, you are caught in a maelstrom of assessments, referrals, applications for benefits and equipment, uncertainty about where to turn, whether you have enough money, who is in charge of what, whether you can trust the care home down the road or the carers who come in to your house, whether you are making the right decisions, often on behalf of someone who used to make all their own decisions... And when it is over – and for some people this can last a long, long time – mostly people feel quietly relieved and pick up the threads of their own lives.
These are silent, private crises happening in hundreds of thousands of homes across the country. Not everyone has family members to help. It takes extraordinary energy to tell your story and demand change, as seven people and their carers did for a report commissioned by The Richmond Group, which complements the wider piece of research undertaken by the Nuffield Trust and The King's Fund to examine the sustainability of the social care system.
What a family or an older person experiences is highly variable, often inexplicably so. It depends on their own levels of wealth – this much is known – but, more than that, is deeply intertwined with local variations: variations in the supply of care homes, the financial health of the local authority, the availability of care workers, and the availability of NHS services 'in the community'. It is unsurprising that older people are not clear about what help they should be entitled to, or who is responsible when it doesn't materialise.
So what will make this system change? Will there ever be overwhelming public pressure for social care reform? My King’s Fund colleague Richard Humphries has previously set out the litany of inquiries, commissions and calls for change that have gone nowhere. Most politicians avert their gaze. Will they do so again?
Thorlby R (2016) ‘Where is the public pressure for social care reform?’. Nuffield Trust comment, 15 September 2016. https://www.nuffieldtrust.org.uk/news-item/where-is-the-public-pressure-for-social-care-reform