Where next for adult social care in the UK? Thinking beyond the crisis

In her recent SCIE blog, Kathryn Smith, SCIE’s new CEO, asked: ‘Are we simply trying to put the sector back together, like it was before? Or are we going to think bigger – about how we build a sector fit for future generations?’ Here, Sustainable Care team members Diane Burns, Catherine Needham and Sue Yeandle discuss challenges ahead for care in the UK.­­­­­­­­­­­­­­­­­­­­­­­

Diane Burns

Dr Diane Burns

Co-Investigator, 'Delivering care at home'

Catherine Needham

Prof. Catherine Needham

Co-Investigator, 'Comparing UK Care Systems'

Prof. Sue Yeandle

Principal Investigator, Sustainable Care programme

CN: It’s hard to provide answers in the middle of the Covid-19 pandemic, but the virus has highlighted important issues which will shape likely future developments in adult social care (ASC).

ESSENTIAL WORK, A TOUGH JOB

DB: I agree. The crisis has shown the importance of ASC in the wider economy; that it can’t just be shut down. Care workers have become highly visible as essential workers. And we’ve seen how diligent they are in performing vital social tasks, even when risks of infection were unknown.

SY: It’s also shown everyone how tough their jobs are. And that their working conditions expose them to real financial risk when unable to work. We’ve heard less in the media about unpaid carers – the families and friends on whom our health and social care systems also rely – but we’ll come back to that. Catherine, what does your study of care arrangements in the 4 UK nations lead you to expect may now happen?

CN: Some issues stand out for me. First, differences between the 4 nations are sharpening and extending into new areas, such as when people can cross borders. Perceived failings at Westminster have led leaders in the other jurisdictions to further distance themselves from a UK approach. This is likely to exacerbate existing differences – in charging policies, the role of markets and private providers, and how the NHS and adult social care connect.

FINANCIAL CHALLENGES

SY: During the crisis, differences in how the 4 national governments approach and value care have seemed more visible too. Another issue is that financial pressures on providers look set to be acute.

DB: I think so, too. More divergence in funding arrangements and increasing inequity seems likely. And in England, if even LAs in more affluent places, or that are trying to be progressive, face acute financial problems, further cuts in funding could make English local authorities more alike, for example in how they commission services.

CN: I also think, whatever the question, politicians will say ‘more health and care integration’ is the answer, even though – as Sally Warren has emphasised – it’s unclear what this means and why it would help.

A COLLECTIVE VOICE?

DB: Yes, we’re already hearing this from political parties and NHS chiefs. Maybe we’ll see a stronger collective voice challenging this, from provider, care worker and social care associations and alliances?

SY: Messaging from sector organisations has been consistent in its outrage over C-19 testing, PPE and risks to staff and residents. But this could shift. Providers range from small businesses to major chains with complex multinational connections and financing. And though care workers share experience of low pay and tough working conditions, their employment status and ability to organise varies. There’s vocal leadership – which is new – but weak organisational infrastructure for care worker solidarity.

WHAT WILL HAPPEN TO CARE HOMES?

CN: There may be a danger that, longer term, negative coverage about care homes will damage the reputation of the sector. That could affect their financial viability – and increase challenges in homecare.

DB: We could see closures as care homes become financially unviable, or are forced to close by regulators. More churn would be detrimental to the care system and quality of care. Some business models will fare better than others – for example groups reliant on financialised debt will be vulnerable to drops in occupancy.

GAPS AND INEQUALITIES

A gulf may open up between homes for the affluent and those taking publicly-funded clients. I’m also pretty worried about care worker supply and how low staffing levels affect job and care quality. It’s good to hear of a recent surge in interest in the nursing profession, but that’s unlikely in social care. Watch what happens with DHSC’s campaign to recruit 20,000 new care workers.

SY: Yes, and as our team researching migrant care work shows, the emerging Brexit scenario and policy on immigration looks set to reduce a key source of caring labour on which we’ve relied for 20-odd years.

WHAT ABOUT THE CARE ACT?

CN: Another concern I have is specific to England. The Coronavirus Act 2020 provides for ‘easements’ that Luke Clements argues ‘radically downgrade Care Act 2014 rights for disabled people and carers’. LAs have used easements variably, but these could be very difficult to lift in an ongoing crisis.

PRESSURES ON FAMILIES

DB: We could see a rise in costly legal actions, too. Care sector insurers seem to expect this. Will new and different powers for regulators follow? This could increase reliance on informal care, despite the pressures family/friend carers already face.

SY: I agree. Carers UK showed recently that families have borne the brunt of the pressure the pandemic’s brought. Yet we know the very groups absorbing this were already under great strain. Our new survey of working carers (coming soon) shows that very clearly.

BUILDING TRUST

CN: You can’t have a new reform settlement for social care without trust. A big fear for me is that the trust vital for care reform will be harder to find. Relationships have worsened between the state and care providers over access to PPE and testing. People with disabilities have been outraged by suggestions that they are not a priority. Older people have felt patronised and discriminated against by risk-based age profiling. Maybe reform will involve a stronger role for local government, where trust can develop locally? Though with local authorities facing 20% cuts that will be tough.

DB: I agree, pre-Covid, the financial pressures on local authorities, at a time of increased demand for social care, had already strained relationships with care providers. However, the market will respond to any increased state funding to stabilise and support social care. Markets always respond to opportunities to make money. Increased interest in the care industry could follow.

And we may also see opportunities to re-examine the role and responsibility of state and market, with new controls. The ‘Foundational Economy Collective’ favours ‘social licensing’ – regulation with social and environmental obligations on foundational service providers. In social care this could make offering secure employment a requirement for receiving public contracts.

WAYS FORWARD

CN: Ultimately, social care sits at the nexus between the formal and informal. The informal has done well in this crisis – the mutual aid, help of neighbours, community solidarity. The formal system has struggled, despite some heroic efforts. Most proposals to improve social care – a new funding model; registration of care workers; integration with health – aim to build the formal element of care. There are other ways forward – socialcarefuture suggests ‘start with the people’, talk about lives, relationships and love. That should be a crucial aspect of sustainable social care after Covid.

SY: Perhaps, but limits to what families and friends can contribute must be recognised. The pressures of caring, especially for 20+ hours or more per week, fall heaviest on those with least, so it’s crucial to get their support right. That will mean investing heavily in better support.

DB: Building from what older and disabled people want, and families and communities can offer, in a co-produced way, will be crucial. It requires infrastructural support and new ways of working at local political level.

HOPE AHEAD?

Can some positives emerge in the months ahead?  We have to hope so.

Catherine Needham, Diane Burns and Sue Yeandle

Click the images below to learn more about the authors’ work on the Sustainable Care programme

Delivering care at home

Emerging models and their implications for sustainability and wellbeing

Comparing UK care systems

Prospects development and differentiation in the four UK nations

Sustainable care: connecting people and systems

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