Social care in crisis: your questions answered
Can the government come up with a solution that works for individuals, carers and staff?
Funding for social care is a conundrum that has confounded successive governments. But demographics, nursing workforce trends and the knock-on effects on the NHS mean finding a formula that works becomes more pressing by the day
What’s the problem?
It’s not one problem, it’s several. Local authorities in England struggle to fund people who need care in their own homes or who move into a nursing or care home and are eligible for council support. Where the value of someone's assets make them ineligible for council support, they often have to sell their home to pay their care home bills. Unsurprisingly, this has been unpopular. At the same time, the care home sector is struggling to make an adequate profit – especially where homes are dependent on council-funded residents – and this has contributed to some homes and home care services closing.
Many staff are paid little more than the minimum wage, which makes jobs unattractive and difficult to fill. There are 110,000 vacancies across the sector in England and a staff turnover of close to 30% a year; this could become worse after Brexit because citizens of other EU countries make up 7% of the overall social care workforce and are 16.5% of registered nurses in social care.
'Two years ago, the Care Quality Commission said social care was approaching a tipping point as unmet need rose; this year it suggested that point had already been reached'
While the system is just about holding together for now, predictions for the future are gloomy. For example, the number of people over 85 in 2015 who needed 24-hour care is expected to have almost doubled by 2035. As many as one million new care workers could be needed in 20 years’ time.
All these problems have contributed to care that is not always of the highest standard or available to all those in need. Two years ago, the Care Quality Commission said social care was approaching a tipping point as unmet need rose; this year it suggested that point had already been reached. While more money was being promised for the NHS, its impact risked being undermined by the lack of a long-term funding formula for social care, it added.
I’m a nurse in the NHS – how does this affect me?
Poorly functioning social care is not just bad for those using its services or working in them – it creates problems across the NHS when patients can’t be discharged home or to residential care. It makes hospital nurses' jobs more challenging because they know their patients are not being cared for in the right place and other patients can’t be admitted. Nurses in the community will see patients struggling more if home care is not available. ‘You end up in a vicious circle where money for the health service is spent propping up the underspend on the social care system’ says RCN policy adviser Charli Hadden.
Such is the impact on the health service that a recent poll of NHS finance directors by the King’s Fund suggested social care was their top priority for investment from any increased NHS funds.
'Many long-term solutions appear expensive, there has been little political will to tackle issues where the benefit may not be felt for many years, and there is little consensus about a solution'
It is so difficult to recruit nurses at the moment that some nursing homes are re-registering as residential care providers. Without more money coming into the sector, homes will struggle to match nurses’ pay in the NHS and offer a viable career option.
This crisis has been building for years, hasn’t it?
Indeed. The looming issues with social care have been clear for at least two decades; the effect of ageing babyboomers and increasing lifespan – with increasing numbers of people living with chronic, often complex, health problems – should have been obvious.
The problem is many long-term solutions appear expensive, there has been little political will to tackle issues where the benefit may not be felt for many years, and there is little consensus about a solution.
Part of this is due to social care costs affecting older people in very different ways. Some will face costs of more than £100,000 and may have to sell their homes to fund residential care. Those in England with assets of under £14,250 (excluding their house) have all their home-based social care paid for while anyone with over £23,250 has to fund it all themselves – though many people with lower-level needs won’t get any funded social care.
So nothing has happened?
There have been several reviews and proposals – most recently from the economist Sir Andrew Dilnot, who suggested a lifetime cap on the amount any individual would pay for care. While the government favoured something along these lines, it was later dropped. Last year, Sir Andrew described funding of care as ‘absolute chaos’.
In the run up to last year’s election, Theresa May swiftly disowned a manifesto proposal that people needing social care at home would pay for it until the value of their assets, including their home, was down to £100,000.
Currently, the government is preparing a green paper that will look at potential solutions. But the publication date of this has been slipping. Even if it is published in the next few weeks, it is unlikely any changes would come into effect until well into the next parliament.
What do people want out of the green paper on social care?
The short answer is a long-term sustainable solution that gives a level of clarity to the public and to providers of social care. But, as the UK Homecare Association says, money is ‘the crunch issue’ to meet the increasing demand from older people and those of working-age. How that money is raised is a moot point: at the moment the cost is split between people who pay for it themselves, local councils (who are expected to spend 38% of their income on adult social care next year) and the NHS.
Increasing, total spend is likely to involve higher taxes or national insurance, and/or getting people to save for potential social care costs. However, Simon Bottery, a senior fellow at the King’s Fund, points out there is little evidence that people can be persuaded to save to fund their social care or to take out insurance against costs. He would like to see the green paper outlining a range of options from caps and floors – where contributions are limited to an upper cap and care is free below a lower floor – to social insurance to free care, and drawing on the experience of countries where these have been tried.
The green paper could also point the way towards greater integration between health and social care and needs to be aligned with the NHS’s forthcoming ten-year plan, points out Ms Hadden. The public – which often doesn’t realise how social care works – needs to be engaged in this as well as the workforce.
How much more money is needed?
It depends what you want to do. The Local Government Association has suggested a ‘cap and floor’ system could cost an extra £4.7 billion a year and providing free personal care £6.4 billion. But these would be on top of the £1.44 billion annual costs of paying providers fairly and meeting rising demand and inflation – £2.12 billion a year by 2024-25. Providing care for everyone with ‘unmet needs’ could add another £5 billion to the bill.
The RCN has called for a robust assessment of population need to help guide any new solution for social care.
Why is the social care workforce under so much pressure?
Ms Hadden points out the social care nursing workforce is older than the general nursing workforce, with 44% over the age of 50, and turnover is much higher with around one in three leaving each year.
A better-funded system could help prevent care jobs being treated as 'temporary until something better comes along'. There is particular concern about the knock-on effect of the recent Agenda for Change deal for NHS staff: lower-paid roles in the NHS pay much more than their equivalent in the social care sector.
'The number of nurses available overall needs to rise – but Brexit could make this more difficult and could also have an effect on care assistant numbers'
The number of nurses in social care dropped by 9,000 between 2012 and 2017, Ms Hadden points out, and there is no set pay structure as there is in the NHS. ‘If there is no equity in terms and conditions, it just makes it more likely that nurses will migrate from the care sector to the NHS,’ she says.
The number of nurses available overall needs to rise – but Brexit could make this more difficult and could also have an effect on care assistant numbers. The UK Homecare Association would like to see changes to the visa system to make it easier to recruit from overseas.
So will we see changes soon?
Successive governments have ducked the funding question and, with the government preoccupied by Brexit, there are concerns that further prevarication is likely. Even if it does decide to legislate, changes would be unlikely to come into operation until after the next election. That is bad news for local authorities, which are forecasting a gap of £3.56 billion in social care spending by 2025.
'The crisis in social care does not simply affect nurses in their working lives. Many nurses have family members or friends who need social care'
As a consultation document, the green paper won’t give a complete answer, but it should still be welcome. ‘What we should be looking for is a sense of progress towards a solution,’ says Mr Bottery. ‘We may not tackle all the issues in one go but a sense of direction is really important.’
There may be a need for action now to keep the sector going until more major change. In the past few years, the government has allowed council taxes to rise to allow more spending on social care but this may not be enough.
Ms Hadden says there are some things that could be done in the short term to ease workforce pressures – a national recruitment campaign for registered nurses in social care, more focus on staff health and well-being, and more flexible working to reduce sickness absence and improve retention.
The crisis in social care does not simply affect nurses in their working lives. Many nurses have family members or friends who need social care – and experience the struggle many other carers go through to get them adequate care as well as the effect it can have on their own lives. For them, a solution to the social care crisis can’t come soon enough.
Alison Moore is a health journalist