Adult social care rose to the top of the political agenda at the end of 2016, but local authorities have been grappling with tightening budgets, rising costs and rising demand for much longer. They are responding to these pressures by reducing the number of people who receive state-funded social care and squeezing the fees they pay to the independent organisations that provide it. Meanwhile, delayed transfer from hospital to social care has climbed rapidly.
Spending on adult social care has fallen by 6% in real terms since 2009/10.
Adult social care – the provision of support and personal care (as opposed to treatment) to meet needs arising from illness, disability or old age – is not paid for by the Department of Health. In fact, the money for adult social care comes from one of the most squeezed departments in Whitehall: the Department for Communities and Local Government. Its budget for local government has been cut by 60% since 2011/12, and is set to fall to £3.3bn by 2020, an 88% reduction over nine years.
Within this challenging context, local authorities have shielded adult social care from the worst of the cuts, but spending in this area still fell by almost 10% up to 2014/15, rising last year due to the Better Care Fund. However, this national picture obscures substantial local variation: different local authorities have very different demographic and socio-economic profiles. Research by The King’s Fund suggests that spending on adult social care fell by at least 20% in 25 local authorities between 2009/10 and 2014/15, while actually rising in another 36.
Demand is growing…
The majority of people who receive state-funded long-term social care are aged 65 or over: 67% in 2015/16. The growth of the older population is therefore set to put significant strain on social care services.
Since 2009, the number of people aged over 65 in England has increased by around 16% – with a jump in 2012 (when the unusually large number of people born in the 1947 baby boom turned 65). This is set to rise by a further 36% by 2030. Not all of them will need care, of course, but at 65, most people have at least one long-term health condition; at 75 most people have at least two.
Although the ageing society is often talked about as the biggest pressure on social care, there are many adults under 65 who receive state-funded social care services (285,020 in 2015/16). As better healthcare has improved the life expectancy of people with certain conditions, the number of working-age adults with long-term needs has also increased. Between 2009/10 and 2013/14, the number of adults (18+) living with learning disabilities rose by around 20%.
…but the number of people receiving state-funded care has been reduced by a quarter, with most of those reductions in community care.
Social care, like healthcare, is a demand-led service. But unlike the NHS, local authorities are not obliged to provide universal care regardless of income. Under the 2014 Care Act, everyone is entitled to an assessment of needs, but the provision of state-funded care is based on the severity of those needs and the ability of the client to pay for it.
Thus, despite demographic ageing and other demand pressures, the number of people receiving state-funded social care has actually fallen. Between 2009/10 and 2013/14, it fell by 24% (changes in data collection mean we cannot compare this with more recent figures). This decline is relatively recent – between 2005/06 and 2008/09, the number of people receiving state-funded social care actually increased by 2%.
During this period, many councils explicitly restricted the numbers they considered eligible. Before the 2014 Care Act, councils were free to set their own minimum level of eligibility – whether they would pay for people with low, moderate, substantial or critical needs. Between 2010/11 and 2013/14, the number of councils paying for people with low or moderate needs fell from 27 to 19 (out of 152).
So this reduction in provision has not occurred across the board. Local authorities have prioritised the most intensive (and expensive) types of care, such as long-term nursing care for disabled older people, support for adults with learning disabilities, or extended-hours home visits for those with complex needs.*
It is in the area of community care that there has been the largest decline (28%, or 412,600 fewer people receiving services up to 2013/14). Within this, care packages have been most squeezed, including long-term support or treatment from a professional (down 249,700 to 194,925 people in 2013/14) and provision of equipment such as stairlifts or bath rails (down 154,400 to 357,555 people in 2013/14). The number of people receiving ‘meals-on-wheels’-type services has fallen by almost 70%, and stood at 68,505 in 2013/14.
Box 3.1: What about the rest?
A wide range of things can happen to people who might previously have received state-funded social care, but currently do not. They may:
Local authorities are squeezing the fees they pay to care providers, forcing some out of the market.
Unlike the NHS, local authorities are not able to run up deficits to pay for growing demand. If they have been unable to find sufficient savings elsewhere, some have passed their financial pressures on to the independent (private or charitable) organisations that provide most state-funded social care.
The average fee paid by local authorities to social care providers has fallen by 6.2% since 2011. Providers argue that this is insufficient to pay for their clients’ care. According to the UK Home Care Association, only 10% of councils in the UK paid at least £16.70 per hour, its estimate of the minimum sustainable price for home care services last year.**
The financial pressure on service providers has been further compounded by the introduction of the National Living Wage, which is pushing up staff costs. One estimate suggests that this will add at least £1bn to workforce costs in the sector by 2020. At the same time, social care providers are facing the same difficulties recruiting and retaining registered nurses as the NHS: one survey found a 55% increase in care-home agency nurses between 2013 and 2015.
Some providers have made ends meet by charging higher fees to self-funding clients to help pay for local authority residents: an average of 43% higher, according to one estimate. They might also pass the costs on to their staff – paying only for ‘contact’ time, and not time spent travelling between clients.
Providers may eventually decide to cut their losses and provide services for privately funded clients only – the 2016 Association of Directors of Adult Social Services (ADASS) survey found that 91 local authorities had had at least one social care contract handed back to them.
At worst, these financial pressures are causing social care providers to shut. The number of care homes closing down rose to around 380 between January and June 2016, compared with 260 during the same period in 2013. This is not only affecting poor-quality providers: 36% of the homes that closed between October 2014 and December 2015 were rated ‘good’ at their last inspection.
Meanwhile, people stay in hospital for longer than necessary while they wait for care packages.
Delayed transfers of care occur when someone is deemed clinically fit to be discharged from hospital, but for some reason they remain there longer than they need to. This incurs unnecessary costs to the NHS of around £820m a year.
Overall, the number of people on a given day experiencing delayed transfers of care has increased by around 38% from 4,940 on 26 August 2010 to 6,810 on 27 October 2016. The majority of delays (57% in October last year) are attributable to the NHS, but the number attributed to problems with social care is climbing rapidly. Between 2010 and 2016, the number of days patients were delayed transferring due to social care rose by 45%, from 38,324 to 69,798.
Strikingly, in October 2016, eligible people waited 41,370 days for a care package in their own home, a 234% increase from October 2010.*** This is now the most common reason for patients being delayed in hospital.
Capacity problems within social care – shortages of staff and beds – are not the only cause of these delays, but they are a key contributor. Delayed transfers from hospital also may be a sign of unmet need for social care, where a shortfall in care outside the hospital results in a person ending up at A&E with more acute problems. Overall, the dramatic rise in delayed transfers indicates mounting pressures on both the health and social care systems, as well as the persistent disconnect between them.
The people who do receive state-funded care are as satisfied with those services as they ever were.
Despite clear problems with access, the number of people responding that they are satisfied with the social care service they receive has held up, and currently stands at 64.4%. Of course, this does not tell us about the feelings and experiences of people who do not receive care.
More worryingly, the Local Government Ombudsman saw large increases in complaints last year (25% for home care, 21% for residential care), although complaints data can capture increases in reporting as much as increases in problems.
Ultimately, people’s experience of social care will vary greatly depending on their location and circumstances. The vast majority of providers inspected by the Care Quality Commission (CQC) up to July last year were rated ‘good’ or ‘outstanding’ (71%). But what about the rest?
There are concerns that not only are almost 30% of providers providing low-quality care, but also that they may lack the capacity to improve. Last year, 47% of providers reinspected after a ‘requires improvement’ rating remained at that level, and 8% slipped further into ‘inadequate’. Continued financial pressures will only make improvement harder. In the ADASS survey, 82% of local authority social care directors reported that providers in their area were facing ‘quality challenges’ due to financial pressures.
* In 2015/16, 25% of all adult social care spending went on long-term physical support for people aged 65 or over, and 27% went on long-term support for 18- to 64-year-olds with learning disabilities. NHS Digital, Personal Social Services: Expenditure and unit costs, England 2015-16, Figure 1.3. http://www.content.digital.nhs.uk/catalogue/PUB22240/pss-exp-eng- 15-16-fin-rep.pdf
** In 2015/16, local authorities in England spent £4,997,928 on their own provision, and £14,791,970 on provision by others. See NHS Digital, Personal Social Services: Expenditure and unit costs, England 2015–16, http://www.content.digital.nhs.uk/ catalogue/PUB22240
*** This includes people waiting for community care packages – provided by the NHS – as well as home care packages provided by local authorities.