I’ve been thinking about social care a lot recently. I work in social care, so that’s perhaps unsurprising. Covid-19 has raised particular issues relating to social care too; most evidently the tragic impact upon so many living in care homes and their loved ones. Office for National Statistics data showing numbers of deaths involving Covid-19 by place of occurrence makes for shocking reading. I’ve included the link here:
In addition, local councils have responded to Covid-19 in many different ways, at much greater financial cost than the amounts provided to them by central government (including the promised third tranche of funds to be allocated from central government), whilst income has been reduced (I’ll talk about this a bit more further on), which means that Councils face making cuts to key services to bridge the gap. In my local authority, all members of staff have been asked to consider reducing their hours as part of a larger package of cost savings, which includes cuts to support.
I’m angry and upset about the situation and have had more than one rant/discussion, as my family/friends/colleagues will attest to. I know that many family members/colleagues/friends and acquaintances feel similarly and I thought that setting some of my views and experiences down on paper might make some sense of them. No groundbreaking ideas are likely to be found here, but I hope that some personal views based on experience of working in adult social care might be of interest to some.
I currently work part-time as an Approved Mental Health Professional (AMHP) covering an area which comprises city, town, and rural locations and for S12 Solutions once a week. AMHPS are involved in making decisions regarding admission to hospital under the Mental Health Act, alongside (usually) two doctors. Assessments take place in the community, health-based places of safety, mental health wards and in general hospitals (A&E and other general wards), as well as in police custody on occasion. I work for the local authority (local council), as part of social care services (the AMHP role is independent of the NHS), and am based alongside and work closely with NHS and other social care colleagues in mental health services. Local authorities hold the responsibility to ensure that there are sufficient numbers of AMHPs to provide a service. The team I work in also manages the MCA DoLS (Mental Capacity Act Deprivation of Liberty Safeguards) statutory requirements and my role encompasses this when I’m not ‘AMHPing’.
I’ve worked in social care (in England) for the past fourteen years, with most of this time spent working in adult social care; initially as a support worker, then as a social worker before qualifying as an AMHP/BIA (DoLS Best Interests Assessor). For this reason, I will (try to) focus my thoughts on adult social care in England.
What’s the problem?
In order to provide some structure to the rambling, I have broken down the issues (as I see them) into three broad (but interlinked) problem areas:
- Models of care
Misconceptions about what adult social care is are pervasive and, perhaps tellingly, it’s actually quite difficult to find a definition of what adult social care is, so I came up with one which pulls together different explanations I have read. Adult social care encompasses support provision to anyone aged over 18 in need of personal and/or practical support, with the aim of promoting independence and quality of life. Adult care includes support to people in their own homes, supported living and extra care housing, as well as nursing and residential care homes. Adult social care involves supporting individuals with physical health needs, learning disabilities, autism, mental health needs and care for older adults, although that is not an exhaustive list by any means, and the legislation (Care Act 2014) does not use diagnoses as criteria. Adult social care also involves statutory services like safeguarding adults, MCA DoLS and AMHP teams. The image of social care as involving care of older adults in care homes is not backed up by expenditure on adult social care which shows increasing proportions of budget spending on adults of working age: 64% working age adults compared to 36% older adults (taken from recent ADASS – Association of Directors of Adult Social Services – budget survey report, 2020).
People can privately arrange and pay for care services if they have the financial and personal means to do so, however anyone who appears to be in need of care and support is entitled to an assessment under the Care Act 2014. Adult Social Care is inextricably linked to local councils, as councils hold the statutory duties relating to meeting social care needs, making this the means of securing funding for care services for those who need it. This can come as a surprise to people who believe that the NHS is responsible for social care. Local councils aren’t always the most popular organisations either. Increases in council tax and high business rents in exchange for reduced services aren’t a recipe for popularity, so no opportunities for piggybacking on the good reputation of local councils for social care! Local councils are also political entities with far reaching statutory requirements beyond social care. Whilst significant proportions of local council budgets are usually spent on adult social care it doesn’t always feel that relative amounts of time and energy are spent on the planning and provision of social care services. Councilors are often busy representing their wards with concerns about universal services, such as bin collections and recycling centers, at council meetings I’ve observed.
The NHS and social care are often considered hand-in-hand (and often as one). We have a government minister for Health and Social Care (although rather confusingly we also have a Secretary of State for Local Government who seems to do most of the talking to local councils), and teams often integrate or co-locate health and social care workers together. This makes sense given that it is somewhat arbitrary to try and separate individual needs in the way that we do. In practice, however, means testing and eligibility decisions about adult social care services sets adult social care apart from the NHS. In terms of sheer numbers too, most people will encounter the NHS at some point within their lives, whereas, many people do not come into contact with adult social care services, and for those that do (in my experience) there is often surprise and frustration at the way services are gate-kept via eligibility criteria and means testing. Surprise and frustration too at the complex nature of ‘market’ service provision which was sold as bringing about greater efficiency, but seems to have achieved something else entirely. There are some brilliant care providers, but we don’t tend to hear about them, and we don’t hear our MPs asking us to protect social care services either.
In addition, the NHS is a much bigger and more powerful organisation than local councils. For many years, the discharge of patients from the NHS has been prioritised over the needs of individuals. In fact, the Community Care (Delayed Discharges Etc.) Act 2003 brought about charging of local authorities by the NHS for delays to discharges from hospital. This has developed a culture of pressure upon social care services to respond quickly when people are deemed ‘medically fit for discharge’. Questionable discharge decisions, and rapid re-admissions to hospital are not unheard of. We have also seen prioritising of hospital provision over social care within the Covid-19 pandemic; with government guidance produced in March 2020 advising rapid discharge. Social care services waited another month before guidance was produced. The governmental decision to discharge people from hospital without testing was recently revised to incorporate testing prior to discharge, however even now it clearly stipulates that people can be discharged whilst awaiting a test result. This does nothing to reduce the risk within care home settings, where it is not possible to isolate all residents, often by virtue of their care needs.
Approaches to funding for local authorities and the NHS from central government are also very different. Whilst NHS Trusts have received funding which has not been able to meet demand year on year, many have run huge deficits as a result. Local authorities, by comparison, are required by law to create budgets which balance the books. In addition to this, back in April 2020 a decision was made by central government to clear NHS deficits which amounted to £13.4 billion according to the government’s own press release. I include this as an example of attitudes leading to lower prioritisation of social care, although it clearly impacts directly upon the funding situation which leads into some further discussion of this.
Local councils have seen huge cuts to their budgets from central government over the past ten years. The ADASS budget survey report published earlier this month reflects this, as does the data itself. I have experienced these cuts as an employee (it’s one of the reasons I moved away from case work) and can see the impact it has had on so many people needing support. The annual ‘savings plans’ just keep coming and a whole culture of managerialism has built up (which is somewhat ironic given the public view of managers reflecting inefficiency), to review requests for funding for services. This increasingly means that only the absolute minimum in care provision is made available, sadly. This ‘efficiency’ might be popular at a societal level perhaps, but unsurprisingly is never that popular when personally experienced. Local councils aren’t usually very popular in my experience, and there seems to be a pervasive view that that there is lots of waste which can be cut. My experience is that there really is not a lot left to be ‘saved’. Key services have been contracted out – so no staffing costs there, team managers are doing the work of complaints teams and recruitment staff, with teams having been merged and job titles becoming ever longer.
Covid-19 has seen huge financial costs for local authorities – both in terms of increased outgoings and loss of income. The recent ADASS survey (mentioned above) reports that only 4% of adult care directors in the country are confident of being able to provide statutory services next year. Even with additional central government funding announced last week, many local authorities are reviewing their budgets – which included savings in the first place – to include much greater savings. Some are even considering handing in a S114 notice to central government, which means officially declaring themselves unable to set a balanced budget, although this results in a third party being sent in to make cuts anyway. I think strengthening relationships and action between local authorities is required.
At this point, some might ask what makes local government a ‘special’ case when so many businesses and individuals are facing huge financial issues. My view is that our statutory services are our safety net. When businesses fail or when people lose their homes, statutory services are the ones we fall back on. That’s why we have public services, key services, key workers. With increasing numbers of people becoming unemployed, registering for benefits, and increasing demand for social care services, I hope that there is greater recognition that those people who have been considered “others” are actually “us”.
Models of Care Delivery
Many councils who used to run ‘in-house’ care services ceased doing so and now ‘commission’ care from other organisations. This was done to reduce costs and to make services more efficient. The result of this has been a hugely complex system involving commissioning and contracts or brokerage teams. Finding care and support for individuals with complex needs can become almost impossible, with private providers declining to offer support or offering support at huge cost, and in some cases the nearest possible provider of support being miles from the person’s family and friends. Commissioning of care too frequently means no control and no choice and too often involves human needs being commodified.
The majority of people, when asked, say they don’t want to live in a care home, but many, many people do live in care homes and this dissonance between how we prioritise our own safety and how we prioritise the safety of others is not an easy dilemma to counter. There is a growing campaign that individual rights to live at home should be strengthened which I would support. However, having been asked to complete (many) Mental Health Act Assessments for support arrangements at home which have broken down, I have seen examples of people whose mood and interaction with others has greatly improved in communal settings, although not always the case. It’s much more complex than living at home = good, living in care placements = bad.
Recently, Boris Johnson announced a promise to reform social care. Reform has been discussed and written about repeatedly over the years, and we are currently awaiting a further green paper which has been delayed six times to date. There are countless studies identifying the importance of social factors upon physical and mental health. There certainly is no quick-fix to reform of models of social care.
In the short-term, increased funding and some stability in funding plans from central government is certainly required, although sadly may not be provided which may leave local councils trying to ‘balance the books’ with further cuts to social care.
In the medium to longer term, social care is desperately in need of reform. A widespread lack of understanding about social care and attitudes which see social care given low priority in decision-making result in positive change being difficult to envisage. Means testing prevents access to funding for all but those with the least means, and provision of support (because of overall levels of funding availability) is increasingly the bare minimum. This makes provision of preventative care and support almost impossible.
Matters relating to change in social care require questions about our priorities as a society, and demand thought is given to the relative importance of efficiency, cost and quality of life as objectives. Cross-party involvement and review of the vast resources already available regarding reform is essential. Social care is vital in and of itself. It has not been, and is not being, given the means to succeed, and there are consequences to this for us as a society.