The future funding of social care in times of austerity
It is largely agreed that things are not as they should be in Social Care. Whether we are looking at funding, choice, quality or a coherent frame work of reform based on shared values around dignity and safety, the more important question is how are these going to be agreed, promoted and implemented?
Social care is now at its most critical point in its existence with documented evidence of the negative impact of underfunding on its ability to sustain both quality services and the care workforce.
The gap between the demand for care and the resources available has never been disputed. We can go as far back as the Wanless reviews, nearly a decade ago, where the questions around the future funding of social care began to today’s proposals presented by the Dilnot Commission.
The Wanless review called for a “partnership model”, whereby two thirds of the bill for a service covering the basics would be paid for by the government. The rest would be paid equally by the state and the individual. This would render the service more universal because the end of means-testing would mean people would no longer be deterred from requesting services. The only barrier then as now was the political will and leadership needed to implement the partnership model.
Dilnot has now recommended that we all (except those eligible for free care) pay up a cap between £25,000 and £35,000 towards our own social care within a national framework of eligibility and portability. UNISON agrees that parts of Dilnot’s proposals are a step forward in the right direction of travel.
UNISON however is still committed to promoting a comprehensive Social Care National Service free at the point of delivery, based on collective provision of universal services with clearer integration with healthcare.
In this time of austerity the limited current funding proposals for a future social care service now needs to breach the wider debate of joined up future commissioning of health and social care services. This in turn raises the problematic questions of what the interface will be between personal budgets, voluntary insurance, pooled commissioning and delivering personalised health and social care.
These are difficult questions that at the current sessions of the Health Committee on Social Care, leading witness experts could not confidently answer but chose to emphasise the tensions and contradictions in current social policy proposals and the corresponding funding, legal and delivery reforms.
So where does this lead us as trade unionists and with what choices to recommend? On the one hand we have a proposal that solve some of the funding and issues and a step towards creating a national care framework but which the government appears to be mute on and thus the endorsement of the Dilnot recommendations may not be forthcoming. So are we back to square one?
In particular as any implementation will involve funding the identified gap of £1.7 million and still further costs yet to be calculated if the new funding regime proposals were enacted.
On the other hand we have a care system teetering on the brink of a funding disaster with the threat of further cuts as the Association of Directors of Adult Social Services (ADASS) predicts a further round of £1 billion cuts 2012 to 2013 on top of the £1 billion estimated between 2011 – 2012.
We need therefore to address the future funding of care in terms of short term funding proposals and longer term proposals. The evidence for the need for a short term response and extra funding has been set out clearly by the increasing documented concern over the falling quality of care in England, probably the lowest now in Western European some claim, and the increasing detrimental pay and conditions in the workforce.
The most identified cause of both has been a vicious circle of lack of funding which in turn has produced a downward spiraling pressure on adequate commissioning and inspection practices around quality provision of care and its workforce. This has produced a race to the bottom and what some commissioners have called anecdotally a culture of “suicide bids”.
The Equality and Human Rights Commission (EHRC) has just published its report Close to home An inquiry into older people and human rights in home care (November 2011).
Whilst the report does highlight how much good practice is out there, and what a difference good quality home care can make it also highlights the real barriers to delivering high quality home care across the board.
In its response to the report UNISON commented that its own evidence supports serious underfunding has driven down both workforce conditions and service quality to worrying levels. Given that a carer’s role is the key to a large part of a quality service and the main cost in home care, there must be a focus on how the care workforce is trained, skilled and utilised. Care workforce practices need to be reviewed and this needs to be integral to the funding debate.
Employment practices like “time and task” with the common place selling of fifteen-minute slots off to the lowest bidder does not deliver quality home care. Companies eager to eke out profits become keen to cram calls – how can an elderly person get the care they need if a fifteen-minute time slot is cut, as recent UKHCA evidence suggests – where tasks by the minute are now being costed? And how can a home carer be expected to deliver it?
Workers on already low wages have seen their wages sink further by practices that include not paying travel time between appointments. They also rarely get access to care plans or training. These poor working conditions contribute to high staff turnover, when we know that continuity of care is a real issue for the elderly. This is not an environment where quality can flourish. These kinds of practices need to be seriously reviewed particularly if we want to have a sustainable well trained workforce which is able to meet the challenges of a sector which is expected to almost double its workforce by 2025. UNISON has set out these concerns in a recent report (shortly to be published) and concluded
The lower the pay the higher the churn and turnover rate in the workforce. This benefits no one, making well trained person centred care extremely difficult to deliver” (Cuts in Social Care – the Impact on services and care jobs in the UK – UNISON December 2011)
Low pay (2010 average of £6 per hour of private agency care worker) and the increasing use of stretched “unpaid hours” correlate directly to the high rate of turnover in the workforce. This is currently nearly 24% in the Independent sector which provides approximately 65% of social care. On top of this there is a growing unregulated and unmonitored Personal Assistant workforce now accounting for 20% of the care workforce who have a pressing urgent need for support and mentoring with their rights and responsibilities.
Returning back to the question of funding whilst we need to provide funding in the short term to address the current concerns we need in the long term to widen the funding debate to address some of the issues raised here and the difficult questions being raised in the Health Select committee on Social care.
There is hope out there. The EHRC report highlights how changes could be made to care commissioning to boost standards. This would involve a real focus on quality – and must now happen as a matter of urgency. If we get these right now and agree on the level of quality of care and the standards that we wish to entitle our care workforce to reach for, then the future funding of care will be easier to reach a settlement and how it’s to be paid for.