The only thing wrong with adult social care is government
The government published two contrasting adult social care papers on 22nd February 2022, responding to the House of Lords and Lady Cavendish’s report. The government’s response, though it does include some benefits, fails to address the core problems. The government’s muddle has five main components:
There is no central adult social care HQ equivalent to the NHS, i.e. there is inadequate central direction and they do not even provide the funding.
Total funding is inadequate and central government tries to micromanage with dribs and drabs instead of letting the 151 local authorities who actually manage adult social care do what is most needed. The primary target for funding should be the professional carers. Underpayment, lack of empowerment and too little professional recognition are causing a shortage of carers, likely to reach 35 percent by 2025. The second priority should be making care affordable for those self-funding. The least important is yet more spending on bureaucracy. Central government’s priorities are the reverse.
The Department of Health and Social Care (DHSC) is unbalanced. Apart from health overall and the Care Quality Commission (CQC), it is almost entirely concerned with the NHS and only minimally with adult social care. Yet the numbers employed in the NHS and adult social care are about the same (1.5M) and the need for improvement is probably greater for the latter.
The CQC causes data duplication, waste and fails to learn from the private sector. It needs reform.
The White Paper’s “10 year vision” is idealistic but also unrealistic, bureaucratic and the numbers fall far short of the rhetoric.
The DHSC only got around to responding to the Lords’ report two and a half years after publication. The fifth is probably the most important of its 25 recommendations: “around £8 billion a year in additional funding will be required for adult social care. More will be required in subsequent years as the population of older and working-age people with care needs continues to grow. Roughly half of all public funding for social care is spent on the working-age population.”
The DHSC response was a bit devious:
“...the Social Care Grant, worth £1.7billion in 2021-22 for adults and children’s social care.” Is this extra or just the usual?
“...an increased Better Care Fund of £6.9bn in 2021-22”. The Better Care Fund publishes no annual report showing objectives or achievements; it appears to be a fund for closer working of NHS and local authority bureaucracies with no benefits for front-line carers or those who should be cared for. It is bureaucracy.
Covid subsidies. Necessary but transient.
“...new investment totalling £5.4 billion between 2022-23 and 2024-25 to reform and transform the adult social care system.” In other words, £1.8bn per annum on “investment”. If that means recruiting more carers and rewarding them better, why not say so?
“Beyond 2024-25, an increasing share of the Health and Social Care Levy will be spent on social care in England.” Unspecific.
In other words, the commitment is just a share (half?) of £1.7bn, not the £8bn which the Lords reckoned was needed for carers and the cared for. This inadequate response is consistent with the disappointing December 2021 White Paper: “People at the Heart of Care: Adult Social Care Reform.” The new money was in seven categories: improving social care housing (£300M), IT (£500M), £25M (sweeteners for unpaid carers who certainly deserve whatever they can be given), £30M (local innovation), £70M (local authority admin) and £5M (new website). Social care in England is bedeviled by central micromanagement and the paperwork needed to get any of the funding.
Secondly, the White Paper funding only totals £1.43bn, even lower than the response to the Lords. Then a revised White Paper was published two months later, i.e. 24th February. The DHSC press office was unable to explain what the differences between the two White Papers were. Even the publication date at the beginning remained December 2021 and the url was the same - a bit sneaky that! “Ah ha!” I surmised, they must have corrected the discrepancies noted above. But no, they worsened them: the total funding had further declined to £1.05bn, due to IT dropping to £150M and the £30M local innovation being removed.
The Better Care Fund (£6.9bn more) does not finance carers or the cared for but a bureaucracy issuing instructions and demanding reports. Of course, the NHS and social care should work better together but that should be at the front-line professional level without interminable committees. The best thing the NHS can do is to stick to its last, namely treatment and cure, and leave patient feedback and regulation to the CQC. Front-line professionals can and should liaise directly. The NHS would like to increase its remit to include adult social care but Lady Cavendish rightly endorses the need to keep the NHS and social care (p.6) separate. The tricky issue, to which I will return, is who pays for intermediate care: the NHS or the local authority (social care).
She is quite critical of the CQC, or perhaps of the role of the CQC. For example, it provides no guidance on the training of carers, nor the quality thereof, because “there is no national rating of [training] providers or quality assurance mechanism” (6.4.2). The CQC should be looking at health and care quality as a whole, not nit-picking.
“The [CQC’s] failure to understand business has another consequence: a surprising lack of interest in self-funders who do not rely on government help. About 45% of care home residents pay all their own costs. Overall, around a third of social care is paid for by consumers entirely from their own savings. Yet government has almost no data about this group, and there are few attempts to learn from what choices these consumers make. The CEO of one award winning domiciliary care provider with numerous outstanding ratings from Care Quality Commission told me that he has never received a call from CQC seeking to learn from how his organisation has achieved this performance.” (This paragraph was removed from the second version of Lady Cavendish’s report, published a few days later)
In summary, Lady Cavendish sets out admirable proposals for adult social care (p.12) mostly recognising and paying carers as true professionals and giving them the freedom to do what needs to be done, i.e. empowerment.
Government departments justify themselves by saying they will be “working with” a huge range of other bureaucracies, rather than providing the resources for front-line professionals or taxpayers. For example, the introduction to the White Paper concludes (p.8): “We will also engage with a diverse range of organisations and people, including those who draw on care and support or provide unpaid care, to consider how we can measure success of our 10-year vision.”
Although DHSC is responsible for adult social care, the funding, mostly if not entirely, transits the Department for Levelling up, Housing and Communities. The DHSC’s Michelle Dyson is director general of adult social care but her statistics seem to be just about Covid. It is hard to see how she, and her small team, can be actively managing adult social care nationwide, given the width of the “vision” portrayed in the White Paper.
We are left with the difficult problem of who pays what proportion of the costs of those needing intermediate care, i.e. local authority and medical: the NHS, local authority or the cared-for. Lady Cavendish (pp.9 on) reviews various systems without coming to any simple conclusion. The current system of having NHS and local authority committees haggling for hours over each case is definitely a bad idea. So is the NHS bribing local authorities to get patients into cheaper home-care or care homes.
According to the King’s Fund, the White Paper proposals “add up to something well short of a full picnic”. It aims to be utopian but is unrealistic, bureaucratic and the numbers fall far short of the rhetoric. It can only perpetuate the mess that government has made of adult social care. Responsibilities need to be streamlined and such resources as can be assembled should be directed first towards better training, rewards and recognition for carers, secondly toward helping those who can, fully or partially, self-fund do so in ways that satisfy the cared-for. This includes home and technological improvements. Only then should resources be made available for essential management and bureaucracy. This would reverse what appears to be the government’s current priorities.