A new settlement for social care
Why it's time for the local to decide the national instead of the other way around
In the last of a series of three essays LGiU is publishing on the future of local government, Ingrid Koehler argues that local government needs to control of radically reforming the social care policy framework if central government continues to abdicate its responsibilities.
The facts are bad enough. They've been bad enough for long enough to take radical actions. We have outlined plenty of harrowing facts about adult social care. Others have, too. Some of the bleak facts include:
· Bedblocking - too many older people who could have been discharged are staying in hospital because of the lack of appropriate support at home or a place in a residential or nursing care. There has been a 125% increase over the past four years, with worse to come. The winter of 2017/2018 is 'predicted to be worst ever’, which puts increasing pressure on an already creaking NHS cold weather service.
· Provider failure: care companies are going out of business at an increasing rate. Research LGiU and the Association of Directors of Adult Social Services (ADASS) indicates that provider failure rates are doubling. Which? has recently estimated that 9 out of 10 local authorities will have a shortfall of residential home places within a decade.
· Lack of money: the Local Government Association (LGA) estimates that over a billion pounds is necessary simply to shore up the independent care market.
· Rising demand: there are already over a million people in the UK with unmet care needs against the backdrop of rising numbers of older people as a percentage of the population.
These grim statistics barely scratch the surface of what it’s really like to have inadequate care or to worry about how you can keep your job and look after mum and dad. And yet, no radical action has been taken.
It’s no longer sufficient to outline how the system is letting everyone down or to bemoan the complicated and interrelated circumstances that mean it’s quite complicated to fix on a solution. Instead it’s time to make genuine progress toward an adult social care system that addresses the needs of older people and their families
While there is still much more that local government can do, namely transform the way that care services are commissioned, the social care crisis cannot be solved by local government alone – central government must step in to address this crisis. Yet, it is only through local control of both support and preventative services that we have a chance of helping older people continue to live independent and vibrant lives. This seeming contradiction has led some national politicians to either ignore the important role of local government or to focus entirely on the possibilities of a national care service. But these centralizing tendencies ignore the place of community and connection for people who need care. It is past time for a concerted joint effort from both central and local government to fix things, but if central government cannot or will not act, then it is time for local government to take the power to sort this out.
Why care must be local
The vast majority of interactions that individuals have with government is through local government. Local government and the management of place determines the kind of environment we live in, the kind of community we have and even the background to forming our most important social connections. Councils may not provide us with friends, but they often deliver or at least provide a platform for the places we meet and make friends from community centres, to sports grounds to planning permission which takes account of social needs or licensing for public houses. Local government both understands and supports the social fabric which is knit through volunteering and community services and the opportunities of circumstance and propinquity.
Looking after granny can never just be about paid care. Humans need connection to feel valuable and these connections must be mutual. This doesn't mean that there isn’t an important place for paid-for care, but rather that paid care can never address all of people’s emotional needs as well as their physical needs. Social isolation and loneliness can play a role in overall health outcomes, declining cognition and early death. Neighbours, local social organisations and families all have a role in supporting those who need care and only local coordination paired with deep knowledge of what’s happening in locally can bring these socially vital elements together alongside paid care when and if that becomes necessary.
The 2017 Labour manifesto called for the establishment of a national care service and while this is a better option than some which proposed an NHS takeover of care, a national service cannot help but be prescriptive and policy driven rather than person focused and tailored to individual needs. Like the NHS, there would always be a tension between the hard cases of great need and prevention, rehabilitation and life enhancement. Only a locally planned and provided social services has the potential to combine community and care.
And though social care must be locally determined and locally delivered, local government is not without fault. Local governments have individually failed to address the impact of underpaying for social care and they have continued to commission services in a way which focuses on time and task and drives providers, commissioners and care workers to look at care as units of time alone – without focusing on individuals and their social needs and desired outcomes.
We know that local authority commissioners want to change the way that care is commissioned, but bit by bit we’ve come to a place where it seems almost impossible to wean ourselves away from cost-driven units of time to a more focused way of supporting people to live more independently and improve or to delivery a graceful decline. Most councils support outcomes based commissioning as an ideal, but very few truly achieve it.
The key problem is not lack of will but lack of information. It is not easy to collect nuanced information about people’s changing social care needs, progress toward personal outcome goals or changes to health conditions. It’s harder still to analyse this information in a comprehensive way to support outcomes based commissioning and reassessment of care to provide the most appropriate and tailored social care plans.
Social care at home has not, by and large, benefitted from great advances in the use of technology, but technology can bridge this information gap. For example, Kingston Council is working with LGiU and others to develop new methods for easily collecting and analyzing the right set of information to support integrated care between family members, care providers, the voluntary sector and trusted others to deliver outcomes with people in their own homes. CoCare is an app and information portal that has been developed within local government with care workers and people who need care to truly support outcomes delivery in home care. It quickly and easily gathers information that supports commissioning based on achievement of personal outcomes while putting the persona who needs care at the centre of caring network that can quickly and easily communicate with each other.
Urgent care at the national level
While long term solutions to care funding for individuals of both moderate and reduced means must be solved, there are even more urgent matters. In our recent publication, Paying for It – we looked at the human cost of driving down prices in domiciliary care. Understandably, local authorities are seeking to support as many as people as possible in the face of rising demand and stagnating (at best) and falling adult social care budgets. Rising costs within adult social care, particularly wage bills as the legal minimum wage rises through the National Living Wage, mean that independent social care providers are facing a terrible squeeze as budgets shrink, costs rise and individuals who are eligible for care have increasingly complex and therefore often expensive needs.
We're in a perfect storm for potential failure, a toxic recipe for disaster – local authorities can no longer afford to pay for care for all that need it and providers in many places can only provide decent care and pay their workers decent wages if they do so at a loss. While some providers struggle on for a while or try to re-negotiate prices, no business can afford to deliver services at a loss indefinitely and many providers are exiting the care market through either a strategic decision or through insolvency. There is evidence that the rate of market failure has doubled over the last couple of years and while thus far, local authorities have managed to handle these crises well, there is a limit to how much they can do.
Individual social care must always be determined locally, but councils simply do not have sufficient resources to provide high quality care to everyone who needs it and meets eligibility criteria. This is simply a matter of money. With limited means to raise revenue, councils are dependent on national funding, and this national funding is no longer sufficient. Councils are running out of money and not only is there insufficient funding nationally, there is little clarity at all for how councils might raise sufficient funds locally. Plans for business rates retention and the future of local government finance, like the plans for helping people to pay for care, have been kicked into the long grass. Councils are at the whim of national policy with statutory responsibilities to fund increasingly expensive services without the means to pay for them or the regulatory framework to help citizens pay for services themselves.
While we have been promised a Green Paper on adult social care before the end of 2017, there has been little sign of a steady policy state. The Commission on Funding of Care and Support (the Dilnot Commission) published its findings in May 2011 and some of those recommendations were incorporated into the Care Act 2014, but the fundamental recommendations around a lifetime cap on social care payments
Although the Conservative manifesto did make some attempts to address the imbalance of social care funding where the house rich and cash poor individuals can have home care funded by the state, whereas people who need residential care must fund it from the value of their assets including their homes. This very proposal may well have cost the Conservatives their majority at the snap election in the summer of 2017. The proposal was branded a dementia tax and seen as an end-of-life tax. But it has some hallmarks of fairness. Only a small proportion of the population at large have a huge proportion of public resources spent on for adult social care, perhaps fewer than 10 per cent of older people who need some kind of help to live independently. But perhaps those that have the resources, however illiquid, should be paying for their care, at least to some extent, as they age.
People rightly fear being bankrupted by the cost of care, and maybe that’s why there was such a visceral reaction against these proposals. The trend is that we will live longer, but live longer with a range a long term health conditions that means more of us will need help to live independently. Currently there are almost no effective, affordable long-term financial products to protect individuals, families and their estates from potentially ruinous costs of care.
While it is almost certainly no longer possible for the state to fund comprehensive social care for a significant part of the population from general tax receipts at either the national or local level, there is much that the state can and should do, including doing nothing, that might improve the situation. But all of these options require reaching some kind of political consensus about how social care should be funded, and we can no longer continue with the possibility that the matter will be sorted, soon, if not this year, then next or the next. It matters less what the solution is than that there is some kind of certainty around who pays for what so that financial services can build products around need and circumstance. In the United States, for example, where there is a clear understanding that most individuals will be responsible for the cost of their care, individuals can and do insure against the possibility of needing care in later age and products can deliver assurance against the ruinous costs of either residential or domiciliary care.
Sharing the cost
Although the market is likely to be part of the solution to paying for social care, ideally we can provide more and better than a purely market solution. In terms of health care spending, the UK is at the more generous extreme of cost sharing between the state and individuals. The state directly covers the lion's share of health care costs through (more or less) general taxation. But in terms of covering social care costs, England is on the opposite extreme. Other than those with very few financial assets, individuals in England pay for almost all of their own social care without either state co-payment or a subsidized and regulated insurance market to help people pay for care. In most Western countries, there is a system of cost sharing and mandatory social insurance for both health and social care. But even in countries like the United States where there is little social care cost coverage except for those of limited resources, social care insurance which covers both home care and residential care is available, though generally speaking only for those of relatively generous means. The United Kingdom must look at a system of social insurance to cover later life social care and a fairer system of cost sharing between society and individuals and a fair provision across Great Britain as funding for social care is different in Scotland, Wales and England in decreasing generosity.
This all requires national attention and focus resulting in a national policy framework that understands that social care can only be delivered locally and within a local context. Central government has singularly failed to deliver this. This is not a matter of political colour but a matter of political place. The centre can complain vociferously about the problems local government is causing the NHS through bed-blocking and it can draw up a new social care green paper largely in secret, but without a real solution to the crisis of funding at both local authority and individual family level that does not foist responsibility onto councils and families in what feels like an increasingly punitive regime nothing will be solved. Already there are threats to withhold promised emergency social care funding if bed blocking rises, meaning that much needed cash will be clawed back if hospital discharges cannot be speeded up substantially.
A new settlement for social care
It is time for local authorities to stop advising and start devising. A social care funding model needs to be designed by councils in consultation with practitioners, social care users, family members and yes – central government which can address the fundamental needs of the social care system including refocusing home care from time and task to individual outcomes.
We call on central government to:
· Settle the funding crisis in the short term by making funds available to address the long term funding needs in adult social care.
· Convene a congress of local authority leaders and directors of adult social care in consultation with service users, carers, the third sector, independent providers and the financial services to develop a robust, realistic, resilient framework for social care funding. If central government is unable to do so, then local government must.
· Provide funding for pilots and further research on outcomes based commissioning and evidenced based care planning in adult social care.
Central government must convene a congress of local authority leaders and directors of adult social care in consultation with service users, carers, the third sector, independent providers and the financial services to develop a robust, realistic, resilient framework for social care funding. If central government is unable to do so, then local government must.