In August 2015, the King’s Fund and the Nuffield Foundation set up a project with the title The sustainability of social care services. With the project team due to report this summer, Jef Smith investigates the idea of sustainability in social care.
In social care, “sustainability” is used in a slightly different sense from where it is encountered elsewhere. It is not just about ensuring that services can be maintained; it is confronting — or admitting that there is a need to confront —the even more pressing issue of whether care services will be able to carry on operating at all. Sustainability in this context comes close to meaning simple survival.
The original project brief drew attention to social care’s falling resources and narrowing service user base, which is taking place alongside the intense financial pressures faced by the NHS. Quoting the National Audit Office, the project warned that “national and local government do not know whether the care and health systems can continue to absorb these cumulative pressures, and how long they can continue doing so”.
If the combined brain power of the King’s Fund and the Nuffield Foundation can throw any light on how we might avoid major failures in the system, we should clearly be listening.
Macro solutions, disappointing but clearly realistic, seem to be ruled out. The researchers on the 2015 project proposed to use case study methodology to look in depth at a small number of local authorities, and to approach this issue with a “primarily qualitative focus”. There is no suggestion that a wider-reaching solution will be found or is even being sought. Instead, good practice will be described with the modest hope that others will imitate success where it can be found.
Despite the project’s stated objective of looking primarily at what local authorities as the major commissioners of care services are doing, Richard Humphries, who is leading the King’s Fund end of the work, made a welcome early resolution to also look closely at providers. Writing in September, he pointed out that this involves “more than 12,000 independent organisations, ranging from big corporate chains to small family-run businesses, charities and social enterprises”.
“Unlike the NHS”, Mr Humphries pointed out, “when a social care provider hits the financial rocks, bankruptcy, not bail-out, is the more likely scenario”. He also pointedly adds that “we should take the mounting evidence about the fragility of the social care market very seriously”. It is not generally known that there are three times as many places in care homes as there are hospital beds in England, but the crisis in care attracts only a fraction of the political and media attention given to hospital bed numbers.
Such inattention is certainly not due to a lack of noise from within the social care provider community itself. Anticipating the King’s Fund/Nuffield initiative, the National Care Forum (NCF) published a report in May 2015 called Survive or thrive? with an emphasis on financial sustainability from the perspective of providers. Central to sustainability in this context is the fall in local authority spending by £3.5 million between 2010 and 2014, with the situation continuing to deteriorate. According to analysts Laing-Buisson, there was a net loss of 3000 care home places in 2015. All this is against a background of acknowledged rising demand.
Although the NCF has acknowledged that “no provider has a right to exist”, it has noted that there is a “substantial funding gap” which needs to be tackled “seriously and with urgency”. Yet, since these words were written, the situation has worsened; the delay in implementing the Dilnot reforms, the proposed introduction of the National Living Wage — which will significantly add to many homes’ costs — and the Chancellor’s widely-criticised insistence on leaving the responsibility for increasing resources with impoverished and largely powerless local authorities.
There may be trouble ahead...
Providers may not yet be through the worst. A section heading in the NCF report warns that “the future may be even tougher”, citing continued austerity, a lack of serious transitional funding while service reconfiguration takes place, and competition on staff pay from the NHS.
How, then, have providers managed so far? NCF points to the controversial practice of cross-subsidising — levying higher fees on self-funders to compensate for under-payment by councils — and deep-cutting efficiency gains, but both of these have their limitations. Penalising self-funders is inherently unfair and is limited to areas with a fairly affluent clientele. Reducing costs through improved efficiency sounds easy but is difficult to sustain year-on-year without jeopardising quality.
The central fact remains: under pressure from cuts to central government grant aid, many local authorities are adopting strategies which in a business context would be regarded as totally unacceptable: unilaterally abandoning long established formulae for calculating fees; cutting rates mid-contract; and refusing uprating despite proven evidence of rising costs.
Given such provocation, some providers have simply walked away from publicly-funded contracts, but this is of course not an option in all areas, nor is it one which can be acceptable to potential residents.
Hope for the future
NCF remain optimistic about the future, and the next section heading of its report — “But all is not lost” — indicates as much. It insists that “there are some signs of hope for the future”, and it is true that the Care Act 2014, which came into effect during 2015, requires local authorities to oversee their local care markets. Doubts remain, however, over how they can perform even this oversight, far less intervene effectively, given current conditions.
Perhaps more of a cause for hope lies in NHS England’s Five Year Forward View, presented in October 2014 and now well into implementation. One of its central objectives is the dissolving of the boundaries between health and social care, and although the option of another wholesale reorganisation remains thankfully off the table, some incremental gains are being made.
Several “vanguard sites” for the exploration of new models of co-operation have been established by the Department of Health (DH), including some relating to residential care, and the results of those experiments should soon be showing through.
DH set out a number criteria for the vanguards or, as they express it, the “new shared models of care”. They have, for example, encouraged the formation of multi-agency and multi-disciplinary teams, a focus on residents’ capabilities rather than their disabilities, and experiments with new types of skill mix.
Significantly, DH has also ensured the collaboration of the Care Quality Commission — this should prevent the scenario of a provider attaining a poor grading because an experiment breaches conventional regulatory requirements.
In light of the present situation, it is difficult to avoid the conclusion that for all the talk of sustainability, social care as currently constituted is fundamentally unsustainable.
There is something about this debate indeed which feels more than a little artificial, as if the various parties — the local authorities, the providers associations, even independent think tanks — are talking hard and making resolutions as a means of trying to keep their spirits up in the face of imminent disaster. It is not quite re-arranging deck chairs as the Titanic sinks, but the determination to retain a measure of optimism does often feel somewhat forced.
With thousands fewer older people receiving care services now than was the case five years ago, and some providers actually backing out of what they perceive as a chronically unprofitable market, the reality of the crisis is undeniable.
The case study approach adopted by both the King’s Fund/Nuffield study and the DH’s vanguard programme, for example, has many weaknesses. Good practice is certainly to be praised wherever it can be found, but it is not always instantly reproducible. Areas vary in their demography, culture and history, and the brilliant people who lead the successful projects which make the headlines are not universally available. Also, best practices may be a product of better resources available to a certain provider. Concentrating on the exceptional can be a way of distracting attention from what is feasibly attainable by all providers.
Another of the difficulties is the set of relationships which make up the social care landscape — in particular, nailing down political responsibility for what is going wrong. Central government, in the form of the Department of Health and the Department for Communities and Local Government, insists that buying and commissioning care is the responsibility of local authorities.
At the same time, local authorities say that they are hamstrung by not having enough resources, and place blame squarely with the Treasury. This cycle of blame continues unchecked, and will not be broken by the new — severely limited — powers to be given to councils to raise council charge specifically to fund social care.
So will the process at some point come to some sort of a crisis? Perhaps unfortunately, it probably will not. Talk from campaigners of a collapse of the system are as unrealistic as claims that the NHS will one day suddenly cease to function. Complex institutions, especially those like the care system, wherein such a diverse selection of governing bodies are interacting, do not suddenly vanish or implode so precipitously.
What does happen is that little by little quality seeps away. People with disabilities have to lead lives which are significantly less fulfilled, their dependence brushed aside in an insistence on accentuating the positive. Carers, families and relatives have to cope with higher levels of anxiety and stress as support systems wither. Homes provide services which are below even modest aspirations: fewer and less well; trained staff; poorly maintained premises; less diversified activity programmes and slighter contacts with their local communities. In such a scenario, talk of sustainability sounds hollow; what is happening is a slow, insidious descent into simply not surviving at all.