Now is the time to reform social care

One of the starkest and saddest aspects of the impact of COVID-19 in the UK is surely the numbers of infections and deaths in care homes. Even when the population in the community was under a tight lockdown, we watched with horror as the numbers of deaths in care homes continued to increase.

Secretary of State for Health and Social Care Matt Hancock’s claim to have thrown a ‘protective ring’ around care homes has stuck in people’s minds: largely because of the vivid contrast between this notion and the actual reality of what has happened in care homes in the UK.

This failure to protect care homes isn’t, however, a surprising anomaly or blip. It’s a corollary of years of failure to take control both of care homes specifically and adult social care generally, and to tackle the crisis that charities and think tanks have been warning about and observing for years. So far the best that ten years of Conservative-led governments have offered to tackle this is a non-binding green paper, promised in 2017, yet, astonishingly, has still not been published three years on.

Contrast this with the achievements of the Labour governments between 1997 and 2010 on two major issues that needed tackling, namely: growing pressures in the NHS – including winter crises and healthcare associated infections – and failing schools, with poor pupil performance.

The governments used a raft of measures to tackle both. The NHS saw new targets, new structures and accountabilities at the local level, and national campaigns. Education also benefited from targets, national strategies and innovative approaches to schooling in the form of academies. Underpinning radical reform in both cases was, of course, significant investment.

The results were clear. The NHS met ambitious targets including reduced mortality, increased cancer detection and falling waiting times for access to GPs and A&E, and patient satisfaction unsurprisingly increased. Meanwhile, in education, pupil performance increased significantly at both primary and secondary level.

Now social care urgently needs the same radical investment and reform treatment. So why hasn’t it happened? The failure to tackle this stems, in part at least, from the complex and multifaceted nature of the crisis in social care.

Fundamentally, it’s about a reasonable expectation that everyone should have – that when they need extra support to live with independence and dignity, they should be able to get access to high quality social care based around their needs.

To achieve that for everyone, three major issues need to be tackled.

Funding

Firstly, the biggest issue relates to money. Despite the rapidly ageing population in the UK – the ONS predicts that by 2050, 1 in 4 people in the UK will be over 65 – social care has seen decreased investment, with public spending falling 2.1 per cent in real terms since 2009/10. But funding has a huge impact at the individual level too – over the last six years there has been a 26 per cent decrease in people receiving government-funded support to pay for social care, despite increased need.

Now the importance of care homes in particular has been highlighted, and the status of social care is heightened in public attention, the government needs to capitalise on this by levelling with people that we need to be prepared to pay for social care if it is to be available at the level and quality that is needed – just as Blair’s government levelled with people about the need for tax increases to pay for the NHS. The public discourse is at a crucial point where it could shift, and it’s crucial for the government to seize the moment and convey to people that paying for social care now is an investment in our futures.

When this has been done, the only real way to secure long-term investment and to satisfy the public that their money really will fund social care is a ring-fenced tax. This can’t be simply tacked on to council tax, but needs to be a centrally collected, dedicated tax, so that it’s clear where people’s money is going.

Workforce

A second major issue is the workforce. There are over a million social care workers in the UK as well as hundreds of thousands of other staff including occupational therapists and managers. These workers play a vital role in the provision of social care, so their recruitment and retention is key. So how have we reached the point where almost 1 in 3 social care workers leave their roles each year, with an alarming 73.5 per cent of home care staff leaving within two years?

To tackle this, this moment needs to be seized to give social care parity of esteem with healthcare. The provision of a ‘care’ badge, similar to that worn by many frontline healthcare workers, is a start but it’s far from enough. Social care workers can’t see themselves as of equal value when so many are on low pay. In March 2019, only around 10 per cent of social care workers were earning the Real Living Wage set by the Living Wage Foundation.

In a pre-pandemic world, the government planned to increase teachers’ starting salaries to £30,000 to recognise their dedication, to increase retention and to attract the best talent. The same end goal is even more pressing in the social care workforce. The starting salary for social care needs to be set at a level higher even than the Real Living Wage.

To coincide with this boost, there should be a national recruitment drive. Teach First and Frontline have attracted talented young people into teaching and children’s social work respectively; now it’s time for a high-profile programme of social care training.

With a shortage of 110,000 staff in the sector, it’s also essential that social care workers are exempt from any immigration restrictions.

System change

The third major challenge is more fundamental: how do we reform the hugely complex system of social care, which includes care homes and home care from a wide range of providers, but is also linked to a range of other systems, such as housing, welfare and of course, healthcare?

In such a system it’s not hard to see how some providers fall through the gaps, with 1 in 5 care homes being rated inadequate by the Care Quality Commission (CQC).

To reform the system, the end goal needs to be kept in mind, namely: supporting adults to receive joined-up care and support. COVID-19 highlights the crucial role of communication and coordination between hospitals and care homes in transferring people’s care, with tragic results where this fails.

The relatively new integrated care systems (ICS) provide an opportunity to drastically improve coordination. ICSs will have a crucial role in commissioning and regulating care for their local populations; to ensure this is truly integrated care, social care needs to be properly joined up with healthcare, and both local authorities and care providers need to be at the heart of decision-making.

But we can also learn, again, from NHS and education reforms. Successful academy trusts have taken over the governance of inadequate schools, while outstanding NHS trusts have merged with inadequate trusts, leading to significant improvements. Is it time for outstanding care homes to take over governance of inadequate care homes? Can we support outstanding providers of both NHS and social care to set up new care homes?

The government must seize the moment. With heightened awareness of the need to support social care, now is the time to boost investment and recruitment and to reform the system.