Survival of the social care cheapest?

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The latest shocking revelations about abuse of elderly people in the social care system raise unanswered questions about funding, training and leadership

It is a well-known fact that the social care system has been under-funded for many years. We’ve had so many warnings about unmet need and the funding gap that statements about the size of the current funding shortage (estimated to be £500m this year, £1bn by 2013 and £6bn within 20 years) don’t raise many eyebrows.

They certainly haven’t prompted the four successive governments since the 1999 Royal Commission to grasp the nettle and come up with a new funding regime. But numbers – however large – don’t often provoke an emotive response.

What has moved the public and politicians, however, are the individual cases – of older and disabled people abused in care settings, and of people left unsupported and alone at home waiting for agency carers who never come. However it is very hard to blame the shocking cruelties of a handful of staff at Winterbourne View and now Ash Court care homes on a shortage of funding, particularly given the healthy fees we know they charge. If anything, they show that all the resources in the world won’t guarantee quality care if culture and leadership aren’t right.

Anyone who has first-hand experience of the care system knows that for every cruel and sadistic ‘carer’, there are dozens of dedicated and devoted professionals. For this majority, the culture and leadership are right – and they valiantly support vulnerable people in the face of a widespread lack of resources. But how long can this go on?

There is as a ‘long tail’ in both residential and domiciliary care in the UK: a few large providers with well-known brands and multiple NHS and care contracts operate alongside a vast number of very small, very local providers, caring for a handful of people each. These small fry often rely on local authority block contracts for the majority – in some cases all – of their income. For them, the reality of living in a monopsony (where there is only one dominant purchaser of a service) means local authorities can use their purchasing power to set fees (perhaps below market prices), dictate contractual terms, and arrange bidding wars between providers to exert downward pressure on prices.

Sarah Pickup, the new president of the Association of Directors of Adult Social Services, drew a line in the sand on this state of affairs last week, stating that social care providers needed to stand up to local authorities and refuse to bid for care contracts where they judged the prices would not enable them to deliver the specification.

But in a monopsony, this is easier said than done. When a small care agency relies on a single bloc contract for its income, refusing to bid means putting itself out of business. It would take a brave care agency to count itself out of the race and rely on its competitors to do the same. This prisoner’s dilemma is even less viable given that the care market is so fragmented and diverse – an entire local care market uniting and all agreeing not to bid seems unlikely, given that big providers – benefiting from economies of scale and financial reserves to take on loss-leading contracts – are also in the mix.

The more likely scenario is that providers will remain on the bidding treadmill until personal budgets break up the monopsony and individual contracts replace blocs. But many areas are – geographically and figuratively – a long way from the personalisation rhetoric so readily available in Westminster. Just 4% of care users in Somerset have personal budgets.

So in the interim, providers are faced with cutting services to the bare bones, delivering 15 minute care slots, struggling with staff recruitment and even more with retention, and cross-subsidizing from private clients (if they are lucky enough to have them). It would be a vast generalisation to suggest the abuses uncovered at Winterbourne View and Ash Court are a direct result of a funding shortage – poor pay does not make someone cruel. And we should remember these scandals are not reflective of the quality of care today.

But at the same time, we must face the fact that there are entrenched staffing shortages in the care system, a pervasive sense of being undervalued, and carers still being asked to deliver ‘time and task’, rather than a level of support. Despite providers’ best intentions, the quality of care and the preservation of dignity is eroded. It might not make it on to the BBC’s Panorama programme, but this gradual, widespread decline is the real human impact of an unaddressed care funding gap.

About Claudia Wood

Claudia is Deputy Director at Demos. Previously, she was head of policy and research at the Resolution Foundation and spent 5 years at the Social Market Foundation as a senior researcher and fellow working on early years policy, social mobility and education reform. She spent a period seconded to the prime minister's strategy unit in 2005 to work on the Education and Inspection Bill.

One comment on Survival of the social care cheapest?

  1. Steve Newton says:

    The main macro issue, little talked about, is the inherent ageism in our society. Older and disabled people with care and support needs are not valued like children. If we had had the kind of reports about children being abused in hospitals, as we have recently had from CQC regarding older people, there would have been an outcry and something would have been done. Until there is a shift in underlying values politicians will be able to sweep the ‘problem’ under the carpet or into the long grass. Since the 1980s the aging timebomb has been discused, commissions reported and yet little has changed, indeed funding has been cut – no matter what the coalition try to say.

    Whilst I agree that money does not guarantee quality care, continued driving down fees will affect the quality of life of some of the most vulnerable people in the country. As a recent comment to the Daly Mail campaign said, a country is judged by how it cares for its children and older people. At the moment the UK can only be said to be a third world country given the shocking neglect to fund the social care sector. This is at a time when billions is found for defence projects. There needs to be a significant shift in our values about the care and support of vulnerable older and disabled people.


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