Q. What does 2016 hold for social care?
A. Des Kelly OBE, Executive Director, National Care Forum
In the run up to the Autumn Spending Review, we had the unprecedented situation of major care provider representative bodies calling on the Government, through the joining of the Care Provider Alliance, with the Association of Directors of Social Services (ADASS), the Local Government Association (LGA), the NHS Confederation and the Care and Support Alliance. The call was to commit to redirecting money, saved as a result of the deferral of the care cap, into reversing the decline in the care system. It is a moot point whether this unified call made any real difference. The Minister for Community and Social Care, Alistair Burt MP, argued at the NCF Annual Lecture at the beginning of December that the best deal possible had been secured for social care. By this he meant the addition of a further £1.5bn to be added to the Better Care Fund and the 2% social care precept that local authorities will be able to levy to local Council tax to support care services in their area.
What are we to make of this difference of view? The Chancellor’s Spending Review announcement led to a further joint response from providers, commissioners and organisations representing people using services. It argued that the settlement falls far short of the funding necessary to avoid a crisis within the care sector. In fact, working together, ADASS, LGA, NHS Confederation, the Care and Support Alliance and the Care Provider Alliance called for urgent talks with Treasury, the Department of Health and the Department for Communities and Local Government. This is an extraordinary situation, which is an indication of the shared level of concern for the fragile state of the social care sector and the potential knock-on implications for the NHS.
Arguably, the social care sector is already in crisis. That crisis is largely the result of chronic under-funding within the public sector which, with continued austerity measures, has worsened in the last 12 months. It is occurring at a time of growing demand, resulting primarily from the ageing of the population, alongside growing expectations of people who use care and health services. All care providers appear to be using the same strategy to protect themselves against the pressures caused by cuts to local authority budgets. That is by aiming at the growing numbers of people able to fund the full cost of their care. However, such cross-subsidisation is not sustainable, certainly for the longer term.
Continually rising costs
The Chancellor’s surprise announcement in the Summer Budget Statement in July, of a new National Living Wage (NLW), starting at £7.20 per hour from April 2016 and rising to £9.00 per hour by 2020, captured media headlines while catching most employers off-guard. In my view, the situation was not well-handled by the care sector, which responded to the announcement by saying it would only be possible if local authorities committed to paying more for care. Meanwhile, other sectors responded positively, welcoming the proposal. Don’t get me wrong, the introduction of the NLW will add cost, especially if current differentials are maintained, and it will probably result in some care providers exiting the sector and a further loss of capacity. Although, I don’t think it will be at the levels of 30% being suggested, as dire warnings, by some of the larger corporate providers. However, in addition to this rise in the wage bill, providers are trying to cope with rising costs associated with agency usage to fund apprenticeships, future pensions and Care Quality Commission regulation and inspection.
Managing the integration with health
In 2015, the first part of the landmark Care Act was implemented, bringing a new focus on wellbeing and prevention to social care along with national eligibility and new rights for carers. However, the decision by the new Conservative Government in May to delay the introduction of the funding reforms contained in part two of the Act (saving some £6bn) means at least a further four years of uncertainty and perceived unfairness surrounding the cost of providing social care. In fact, it makes many of the aspirations of the Care Act seem like rhetoric. Early intervention and prevention seems a nice idea but closer integration between care and health (let alone housing) is down to relationships at a local level with deals being made against all odds.
The Autumn Spending Review looked rather different for the NHS, which had its budget increased, albeit on the promise of delivering significant efficiency savings.
However, there appears to be little evidence, beyond the Better Care Fund, that the fundamental relationship between care and health is properly understood by politicians. As a result, the little that was secured for social care, in the way of resources, is ‘back-loaded’ so that it will not be available before 2017 or even later. This has brought concerns that it will undermine the implementation of the Care Act by local authorities and also jeopardise the delivery of the NHS Five Year Forward View strategy.
Continuing workforce challenges
The challenges of the workforce, recruitment and retention in particular, show no signs of diminishing in 2016. For nurses working in adult social care, the situation has got worse, with average turnover rates now reported to be well above 30%. Continued concerns and criticisms of quality add to negative public perceptions and a sense that the sector is in difficulty. This is something of a vicious circle. The social care workforce is ageing, with the corresponding issue that the proportion of the workforce under the age of 25 is only about 12%. Funding for training is under severe pressure and career structures are patchy at best.
Unless the sector addresses these fundamental issues, it is hard not to conclude that a crisis is looming. Similar difficulties are faced by care providers in seeking to secure the best leaders as Registered Managers with succession plans in place to ensure the next generation of senior staff. As a consequence, pay rates for Registered Managers are rising, perhaps as much as 8%, as supply and demand factors begin to have an impact.
The impact of regulation and inspection
CQC is talking tough, despite strong political criticisms of its own performance. It, too, has challenges in recruiting to full strength. However, of all the concerns raised, by me, on a regular basis, it is those relating to inspection, the quality ratings process and associated matters that appear to be the biggest worry for providers and managers.
CQC still has a huge task to complete the ratings for the best part of two-thirds of care services by the end of 2016. Nevertheless, some interesting information is emerging from the 9,000 or so evaluated and rated so far. Around 30% of services rated so far have been judged as ‘Requires Improvement’ or ‘Inadequate’ which, I think, is high. However, it is difficult to know if this proportion will remain once all services have been rated. The ratings system is arguably still bedding in and, clearly, it is not an exact science. I predict that 2016 will see more legal challenges as providers seek to defend their reputation and their services, but it may also lead to further loss of provision and capacity.
What about winter?
2015 started with regular headlines and news stories about local crises caused by the fact that hospitals were full – mostly of older people. The Department of Health has been developing a resilience plan to avoid a reoccurrence of the situation for this winter. It is unlikely that hospitals (and the NHS) will be able to avoid this completely, for many of the reasons covered already. There are fewer places available in hospitals, despite growing demand, and there will probably be less capacity in care homes or domiciliary care as providers exit the sector. Winter will come and it will bring pressures with it, whatever the weather does. Unless there is a more joined-up approach to health and care services, it is hard to see an improved situation as soon as next year.
I realise that this assessment of the next 12 months is somewhat bleak – I believe it will be. That is not to disregard innovative and quality interventions in care services that I know to be happening. Many of the inspirational work by care providers was abundantly evident at the recent 3rd Sector Care Awards and it is great to celebrate such achievement. However, overall 2016 will be an even more challenging year for the care sector than the one now ended.
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