The adult social care sector provides care for adults with a range of support needs including those with physical or learning disabilities and older adults, many of whom have dementia. These are some of the most vulnerable members of our society as well as being groups of people who are more likely to have significant healthcare as well as social care needs. As the election approaches, it is noticeable that while healthcare is a key policy and funding area, social care is far less prominent and it is useful to examine some of the reasons and implications for this. The adult social care workforce in England in huge, in 2013 it consisted of an estimated 1.45 million people which is on a par with the NHS England’s staff of about 1.3 million. A key difference between health and social care is that social care funding is means tested and even those who meet the financial criteria may not have the high level of care need that is required to access publicly funded support. Not only is the source of adult social care funding split between public and private, but the provision is hugely fragmented. While the majority of healthcare workers are employed through the NHS, social care staff are employed by one of the 17,300 mainly private organisations or through the direct payments of users. Despite the obvious overlaps and interdependence in their roles, the NHS and social care have been uneasy bedfellows since the inception of the NHS.
Social care, while being similar in size to healthcare and providing support for many of the same adults, lacks both the political and media clout of the NHS. In the run up to the elections, the NHS is a key battle ground, with future NHS spending set out in party manifestos; in contrast the budget plans for social care have not been stated in clear terms. There has however been renewed discussion across the political spectrum regarding health and social care integration, including integrated budgets. Recent news stories have revealed that part of hospital bed shortages is linked to wards being unable to discharge patients back into the community as there is inadequate social care for them. The public are rightly angry that money is being wasted and patient care is at risk due to failures of the wider system. This is a prime example of two interconnected systems that should be working together, struggling to do so. Improved links between health and social care have been on the agenda for decades, but coherent, national integration requires additional funding. An NHS transfer of £900 million was intended to support integration, but in the context of a 3% fall in social care funding since 2008/09 while the need for social care continued to grow, in reality it has mainly been used to plug funding gaps to keep basic social care provision afloat. Any talk of integration or improvements to social care, without a transparent funding plan that allows for the increasing needs of an ageing population, looks like little more than well-meaning rhetoric.
Problems occur in both social care and healthcare, but these are often portrayed and responded to differently, leading to diverging political outcomes. Cast your mind back to the last time you heard about either care homes or homecare staff in the news. National stories have revolved around poor quality care and abuse scandals, care staff being underpaid or not receiving the national minimum wage and care being delivered by staff in 15 minute time-slots. The NHS has similarly received very negative press and there are of course some very prominent recent scandals. The difference is though, that when care home or homecare abuses occur, often individual care staff are disciplined (or convicted) and individual care providers are inspected and sanctioned. The wider policy and funding context is not put under the same scrutiny of a public review as the NHS was in the Francis Enquiry.
To give a less extreme example, I was part of a research team studying quality of sleep in care homes. One of the findings was that residents were spending an average of over 11 hours in bed at night and that bedtimes and getting up times were often not a choice but a compromise. A very simple way of looking at this would be to say care staff are not enabling choice in relation to a basic care need. However, a closer look revealed that resident bedtimes revolved around staff shift patterns with more day staff being available than night staff so residents who needed help went to bed when the day staff were there and didn’t get up again until they returned. So it could be argued that the care home management are responsible as they set the staffing levels and shift patterns? Well yes and no. Care homes’ fees, including those paid by the council are set using staffing cost calculations. These allow for lower numbers of care staff ‘at night’ and ‘night’ is typically 12 hours long. Increasing the daytime shift(s) has an associated cost which would increase fees. Therefore an important element of care is neither in the control of residents or care staff, but subject to organisational structures which are in turn constrained by wider funding policies.
It is perhaps telling that the social care sector has still struggled to recruit and retain staff during the recession. Too many care staff are being paid too little, while being expected to be better trained for an increasingly difficult job. Given the projected increase in both health and social care demand this is no time for political stagnation, but promising words are not yet being met with adequate action. Meanwhile, the focus on ‘bad apples’ in social care is avoiding the structural deficiencies that are letting down too many of our social care staff and those that they care for.
Dr Rebekah Luff is a Senior Research Fellow at the National Centre for Research Methods and her research interests includes social care for older adults.