As we head towards a general election, the age-old debate over who is best placed to deliver social care – ‘for profit’ or ‘not-for-profit’ providers – inevitably surfaces. For some, the belief that social care should only or predominantly be delivered by not-for-profit organisations, rather than the mixed market we currently have, is irresistible.
It is a little like when George Orwell wrote in Animal Farm, ‘Four legs good, two legs bad.’ In this case, suggesting animal superiority over humans. I hear repeatedly, ‘Not-for-profit good, for-profit bad.’
Let me say at the outset that I fully support not-for-profit providers and see them as a vital component in the delivery of care. But I do view them as part of a mixed market approach to delivering care that includes choice.
There have been repeated calls from the sector for us all to speak up for social care ahead of the polls and make the case for not-for-profit provision. I agree wholeheartedly with this desire to see social care become a key issue at the election. But I believe that we should campaign for all social care provision – we need to support the sector as a whole.
Whilst some call for a predominantly not-for-profit approach, others favour nationalisation. But to switch social care over to a solely not-for-profit model or to nationalise the sector would cost billions of pounds and take many years to achieve. The country has neither the billions required, nor the time needed. That is arguably why neither is being put forward by any of the main political parties. In these extremely difficult financial times, they may be perceived to be non-starters.
The bigger picture
Looking at the wider argument, should there be such a desire to demonise profit in the delivery of care? All providers have to stay in the black or face deregulation by the Care Quality Commission (CQC), whether you call that a profit in the private sector or a surplus in the not-for-profit sector.
Furthermore, if they are to survive against the competition and keep their CQC ratings high, private sector providers must invest a large proportion of their profit into maintaining high standards of service that respond to the communities they serve. Good-quality care is surely everyone’s aim, whether you make a surplus or a profit.
Most care in this country is provided by small- to medium-sized operators who are embedded in those communities and doing their best to provide a good quality of care, pay their staff as fairly as they can and make a living.
We have seen many examples in recent years where providers have exited the market because they could no longer achieve one or more of those goals. Just because you are a not-for-profit provider does not make you immune from the challenges everyone in the sector currently faces. The problems are the same: staffing shortages, poor fee levels, debt repayments, huge utility bill increases and so on.
Changing perceptions
In any field, including care, there will be instances where large companies grow and pay their senior management in accordance with that size and their responsibility. Yes, there are some highly paid CEOs of care companies but there are some highly paid CEOs of charities too. Not every penny generated by not-for-profit social care providers goes back into providing care. They have costs and salaries to meet as well.
In the main, private sector social care delivery is carried out by smaller and medium-sized businesses, many of whom are simply trying to make a living and not making millions. That is a message that doesn’t always get across and we need to work harder to make sure it does. That might go some way to alter the perception of independent care providers.
These providers want to pay their staff fairly – just as not-for-profit providers do. But to do so we all need reform of commissioning too, so that those buying care – whoever they buy it from – pay a fair price that enables that provider to deliver the care properly and give their staff the pay and conditions they deserve. At the moment, fees paid by many councils don’t cover paying staff the National Minimum Wage, let alone paying staff better and running the business.
Promoting choice
A mixed market of social care provision gives people choice. It would be wrong to deny people the choice of what sort of care they receive or where they spend a very important time of their lives.
Attempts to deliver social care via the public sector have been made before but proved too costly. To suggest renationalising social care would risk returning to that time when the state simply couldn’t cope. And to make not-for-profit the only player in the game would take a seismic shift that would take many years and cost billions.
We certainly don’t claim to have all the answers and are not welded to the old ways of doing things. A model of social care delivery similar to that currently adopted by GPs in this country might work. After all, GP practices are effectively businesses providing healthcare services to their locale under contract to the NHS and Integrated Care Boards. That contract arrangement gives them the security they need to invest in their practices. Giving the same contract arrangement to social care providers could encourage them to do the same. An idea I think is worth exploring at least.
Managing solutions
Providers have solutions to the sector’s shortfalls which would put social care back on an even keel, without breaking the bank. In our Five Pillars for Social Care Reform, the Independent Care Group (ICG) suggested ring-fencing a percentage of GDP for care, creating a joined-up National Care Service, setting a minimum carer wage, establishing a task force for reform and creating fair tariffs for services, such as care beds and homecare visits.
There is no getting away from the fact that some extra investment is going to be needed – we have been deprived of money for so long we have to catch up. But it needn’t all be new money. Every penny spent on social care saves money for the NHS by keeping people out of expensive hospital beds and instead, cared for in a place of their choosing such as in their own home, supported living or in a care home. So, a switch of resources from NHS to preventative social care is surely a no-brainer, as it saves the NHS money and puts resources where they are needed, looking after people where they want to be looked after.
The creation of a health and social care levy – where an increase in National Insurance is used to pay for improved health and social care – seemed, whilst not ideal, at least an attempt to help ease the pressures. I was left feeling very dismayed therefore, when plans to help were shelved yet again.
There is a real fear in politicians over asking the public to pay more – even when it is for our own care. I struggle to believe that the public would resent paying a little more in National Insurance or taxation if they could know that healthcare and social care for themselves and their loved ones was going to be guaranteed and free at the point of need. At the moment, if you need long-term care there is a very good chance you will end up selling your home to pay for it – even if you have dementia, a condition every bit as debilitating as cancer and heart disease, treatment for which is paid for by the NHS.
The message is clear
The ICG has been calling for sensible and sustainable reform, including the creation of a joined-up National Care Service, better commissioning practices and improvements to staff pay for three decades.
The Building Capacity and Partnership in Care document set out perfectly what needed to be done by Government, commissioners and independent sector care providers to deliver good, sustainable care with those needing care at the heart of it. However, that document was published in 2001 and never properly followed through. If it had been, the sector may not be facing all the issues it is today.
We must work with what we have. Properly funded, the mixed market provision we have created since the 1990s would work very well in providing good standards of care and choice for recipients and excellent value for money to the public purse.
But the key phrase there is ‘properly funded’ because at the moment, the sector is not and local authorities are failing to commission care at a rate equivalent to the fees needed to deliver that care, with the result that providers of all types are struggling.
Social care needs to campaign, with a unified voice, for change at the coming general election. Side debates over what type of care we should or shouldn’t be providing serve merely to distract and give opponents opportunity to accuse social care of being a divided, splintered sector.
However we provide it, what is important is that we create a sector that delivers the good-quality care that people need and pay the staff properly for doing so. At the moment, we aren’t doing either. That is what we should be fighting for.
How else can the social care sector express its unity ahead of the next general election? Leave a comment on this article or join the conversation to share your thoughts.
Mike Padgham is Chairman of the Independent Care Group (ICG).
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