How to build a better social care system

Social care in England suffers from deep structural problems. There were over 1.8 million new requests to local councils for adult social care in 2015/​16 including young adults with extra support needs and older people. Austerity has devastated the institutions that provide care for adults in this country, whilst the funding gap in social care is at £2.5 billion and rising. A rapidly aging population is increasing the demand on a system already on its knees – in the UK, the number of people over the age of 85 is expected to double by 2030, and demand and cost pressures for social care are growing at 3.7% a year. 

This has serious knock-on effects on the NHS too – between 2010 and 2017 the number of people with social care needs who were stuck in hospital beds despite being clinically fit to be discharged rose 77%. This is costly — the NHS spends around £820m a year treating older patients who no longer need to be in hospital. The human costs are also staggering – cuts in health and social care have been linked to 120,000 excess deaths in England alone, with over-60s and care home residents being most affected.

The future of social care seems bleak. Vital extra funding does not appear to be on the horizon whilst the government is wedded to the notion of austerity (although the Government’s recent announcement of additional funding for the NHS suggests we may be witnessing something of a departure from this). As with healthcare, many commonly advocated solutions focus on how to raise money to plug the gap and little else. However, in addition to much needed funds, there are very real structural changes to the social care system which we can begin making now.

Care as an economic driver

What is needed is a fundamental shift in the way social care is viewed in England. Care, and the rest of the ​‘foundational economy’, should be at the heart of the government’s approach to industrial strategy. Investment should have direction, and its mission should be to support people to live the best lives they possibly can. Social care should be viewed not as an endless black hole sucking in money, but instead as a key driver in the UK economy. After all, care is already a major economic sector, employing 1.58 million people in England alone and contributing over £40 billion a year to the UK economy. Moreover, it is expected to grow for the foreseeable future: if the adult social care workforce grows proportionally to the projected number of people aged 65 and over then the number of adult social care jobs will increase by 31% to around 2 million jobs by 2030.

Move away from ​‘too big to fail’ providers

In order to maximise the effectiveness of money spent on social care, we need to move away from a system dominated by a small number of very large providers – not only because the money can be better spent elsewhere, but also because the failure of a single large provider constitutes a severe systemic risk. Social care spending represents a mixture of home care and community provision, as well as care home provision. For social care to become truly sustainable in the long term, we need to shift funding away from big providers, and towards supporting an ecosystem of community based, small scale, co-produced forms of social care with a focus on prevention.

New Economics Foundation research revealed that of the £2 billion pledged to social care in the Spring 2017 budget, £115 million would go straight into the pockets of investors in the five biggest social care firms (assuming the entirety of the pledge was invested in residential care). Giant care providers dominate the sector and spend as much as 29p of every £1 in public money on their private investors. They are increasingly ​‘too big to fail’ – whilst some are at the same time operating on the edge of complete financial meltdown. Four Seasons Health Care – the second biggest care provider in the UK – teeters on the edge of collapse after finishing 2017 with just £26m of cash and a net debt of £539m, leaving it unable to make interest payments. Private equity firm Terra Firma Capital Partners and hedge fund H/​2 Capital vie over the failing organisation as they seek to extract profit.

The commodification of care means vital support is susceptible to the whims of the market – we are left with a situation in which care homes are viewed primarily as financial assets rather than essential services. As Carillion​’s collapse has made clear, the marketisation of public services is riddled with risk and we can no longer use it as a standard model to meet the needs of the population.

Look towards a future of community-scale provision

The models of social care most beneficial to local economies are those in the public and voluntary sectors — for every £1 spent on public sector care provision, an additional £1.94 in value is added to the local economy, compared to just £1.32 spent in the private sector.

Community-scale providers also offer the highest quality of care, and smaller homes are generally better rated by the CQC than large homes. They offer more personalised, innovative and valued care for a similar or lower cost than larger providers do.

Perhaps most importantly, by nurturing a broad ecology of community-scale social care organisations, the risk inherent in the current system can be thoroughly mitigated. Should an organisation fail, it will not lead to a complete system meltdown in care provision — as we face now with Four Seasons still on the verge of collapsing.

Social care from the bottom up – a focus on wellbeing and prevention

Glimpses of what this future of social care should look like already exist. The New Economics Foundation has been conducting research with community-businesses like Greenslate Community Farm and North East Dartmoor Care (NED Care), which has shown these organisations to be highly networked and embedded in the local community. The care in these organisations is highly personalised, and delivered by dedicated staff who are paid fairly, and often well above the industry average. Focus is maintained on building and maintaining social relationships, and the autonomy of the individuals receiving care is prioritised.

Crucially, within these organisations care is done ​‘with’ people, rather than ​‘to’ them. Many of these organisations carry out services which have been described by commissioners as being on the ​‘edges of social care’ – i.e. activities which maintain relationships, reduce isolation, and increase mobility for those individuals who may not qualify for social care. But those people supported are certainly at risk of needing more acute forms of care without these interventions.

As we look towards an alternative model of social care, we can see that it is exactly these community-scale organisations who will be most suited to delivering quality social care for a population with growing needs. Rather than being on the edges, these organisations should form the cornerstone of a preventative social care agenda focused around wellbeing and laid out in the 2014 Care Act. Moreover, their focus on autonomy and networked relationships fits into a view of social care which focuses on the broader social-determinants of health. As much as 90% of what makes us healthy are social, economic, environmental and cultural factors which shape the conditions in which we live.

BS3 Community in Bristol provides an example of an organisation whereby volunteers who would otherwise be at high risk of needing social care run many of the activities in the centre. The activities they help run, the socialising and healthy food in the café, and the relationships they build through BS3 all contribute to their continued health. 

These ideas are discussed further in our forthcoming report on the role of community businesses in the future of social care.

Commissioners should use their market-shaping role to nurture this ecology of already existing community organisations – and look to uphold the values set out in the 2014 Care Act. The current system is broken and in a state of crisis. An alternative future for social care does exist, and we need to move towards it with the urgency it demands. 

A different version of this article was originally published on the Social Care Future blog.