Tackling the crisis in care

The case for investment in social care

Tackling the crisis in care

Introduction

Health and social care are two sides of the same coin, under invest in one and you undermine the other. That is at the root of many of the problems in the NHS today. Despite substantial investment, one of the major reasons why the NHS is struggling to deliver, is that the capacity in the care system outside the acute sector is in crisis.

The symptoms of this under investment in social care are delayed discharge and emergency readmissions. The consequences to the NHS are that cancelled operations and trolley waits in A&E for a bed.

However, the funding pressures in Social Services are not confined to adult and elderly services. In fact, the bulk of the pressure comes from children's services.

This paper sets out a rationale for a substantial investment in social care to close the gap between what the Government thinks needs to be spent and what Councils spend on these services. The following paper sets out how the Liberal Democrats would act decisively to restore confidence amongst care providers and social workers alike.

Budget pressures

According to the most recent survey of social service spending by the Local Government Association, budgetary pressures have intensified. In the year to March 2002, Councils expect to overspend their budgets by £218m. Children's services account for two-thirds of the overspend. This is on top of the planned expenditure of £1bn in excess of what the Government thinks Council's should be spending on social care. This is discussed below.

Older people account for approximately 62% of social care service users, but only represent 47% of spending on social care. The Government Actuary's Department projects that the number of people in England aged 65 and over will rise from 7.8 million in 1996 to 12.4 million in 2031, an increase of 60 per cent. The number of very elderly people (aged 85 and over) will rise even more rapidly, from 0.9 million in 1996, to 1.7 million in 2031, an increase of 88 per cent.

According to the LGA, seven out of ten Councils have tightened or propose to tighten the way they ration care as a way of controlling spending pressures. Only the most frail and dependent can be cared for.

Care is increasingly being rationed by:

In describing the consequences of this rationing the National Association of Citizen Advice Bureaux (NACAB) report Rationing Community Care, said:

"Excessive targeting of scarce resources on those in greatest need is leading to inadequate preventative measures in terms of support services in the community for both carers and care users, which may result in more costly institutional remedies becoming necessary.”

Closing the reality gap

For over a decade, there has been a growing disparity between what the Government thinks should be spent on social care through the standard spending assessment (SSA), and what local authorities actually spend. In the early 1990s, the gap stood at about 3% and rose to about 8% by the mid 1990s. The trend has continued so that today, the `reality gap' stands at £1bn, or 12%. The table below sets out the trend.

Source: Local Government Association Note (1) provisional figures (2) forecast figures

It is becoming increasingly difficult for local authorities to divert resources out of other service areas in order to address insufficient SSA's for social care. As a result, the cost falls disproportionately on the council taxpayers and leads to further `stealth taxes'. The Local Government Association has proposed that an additional £400m to the baseline funding would address the increase in the gap between 1998/99 and the forecast out-turn for 2001/02.

Children's Services

`Children Looked After'

Between 1996 and 2001, the number of `children looked after' or in care in England rose from 50,600 to 58,100, an increase of 15%. There has been an increase of 55% in the number of `children looked after' who have suffered from incidences of abuse or neglect.

Other factors behind the increased demand for children's services include:

Foster Care

Given that two thirds of `children looked after' are placed in foster care, there is a need to address the shortage of carers. Social Services departments are finding foster carers increasingly difficult to recruit.

To secure continuity of supply, stability of placement and ensure better outcomes for children, local authorities need to:

Adoption

Adoptive parents should have the right to an assessment of post adoption support. The provision of a coordinated, multi-agency package of support and allowances would encourage more potential adopters. The involvement of health and education services at the assessment stage would help to ensure that a package of services were provided to meet the developmental needs of the adopted child and support needs of adoptive parents.

Children Leaving Care

From October 2001 the Children (Leaving Care) Act 2000 placed new duties on local authorities in respect of young people leaving local authority care. Local authorities are required to provide support for children until they are 18 and to provide assistance until the age of 21. Specific responsibilities include the provision of accommodation and maintenance up to the age of 18, provision of personal advisers, support and advice about education and training.

Currently 2 in 3 children leaving care do so without any formal qualifications. On the most recent figures, just 5% have five or more GCSEs.

Source: Department of Health

Children's Commissioner

In the UK today, 36,000 children are on child protection registers at any one time and one to two children die every week from abuse and neglect. Inquiries into child abuse deaths are conducted in private and the majority are not published widely. Information about the findings of such inquiries is not systematically collected nationally and nobody is sure how many reports there are or where to find them. A Commissioner would help ensure that children are better protected, by highlighting the problems with existing systems, making recommendations for necessary changes and pressing the Government to act on the proposals made by child abuse inquiries. The Liberal Democrats would establish a children's commissioner for England to ensure that vulnerable children receive greater protection.

Services for Adults and Older People

Pressures in the system

Just as Children's Services are experiencing serious demand and budgetary pressures so too are services for adults and older people. The reasons for this include:

Whole Systems Issues

Delayed discharge from hospital is a symptom of a lack of capacity in the care home sector and consequential rationing of access to home care. The Government response has been to allocate £200m in 2002/03 to this problem, but there has been no commitment for subsequent years. The problem is that without secure long term funding, the instability in the sector will not be reduced and problems will remain.

Adopting a `whole systems' approach requires investment in order that a range of services are developed and sustained to avert hospital admission, offer home based care and ensure an adequate supply of care home places.

As proposed in the Wanless report, there must be a whole systems approach to health and social care. Investment in social care would reduce unnecessary costs to the NHS and make for a seamless provision of service.

Based on final National Health Service trust accounts for 1999-2000, the latest published figures, the average cost of treating a patient in hospital is estimated to be £1,630 a week. Based on data provided by local councils for 1999-2000, the latest year for which data are available, the average gross cost of keeping an older person in a nursing home in England is estimated to be £319 a week.

Those older people who are experiencing delayed discharge can be looked after for almost 1/5^th of the costs of being looked after in a hospital bed.

Home Care

Between 1996 and 2002, the number of residences receiving home care has reduced by 124,300 from 491,100 to 366,800, a reduction of 25% in 6 years. At the same time, the number of hours of care per home visited has increased by around 11%. This reduction in the number of households is as a direct result of Social Services departments tightening their service eligibility criteria. While some of the increased emphasis on intensive home care is a result of policy, it has largely been as a reaction to budget restrictions. This change needs to be reversed with the provision of low-level support directed at people most at risk of losing their independence.

Difficulties with recruiting and retaining staff, and increasing demand for the service, are leading to a restricted supply and price increases. Without additional investment to meet both fee and demand pressures the local authority response is likely to be increased charges and a further tightening of eligibility both of which would further contribute to delays in hospital discharge, which in turn results in more cancelled operations, and longer waits throughout the NHS.

The provision of efficient and effective home care services is both socially and economically more viable. Socially, it allows an older person to remain in his or her own home for as long as possible. Economically, the cost and opportunity costs of an acute bed in a hospital are far higher than the cost to the taxpayer of providing appropriate care in the community.

Residential Care

There are two main reasons why Social Services struggle to cope with hospital discharges - lack of funding, and in some areas, lack of residential provision. In a market which is under funded, where capacity has been lost and where local authorities are not the sole purchaser, restoring confidence requires long term investment.

Over the last five years 49,700 beds have been lost in the long term care sector in an unplanned way. Since April 2001, a further 12,600 places have been lost. 1 in 6 nursing homes have closed in the last 4 years. There has been a decrease in nursing care capacity, but there has been no similar drop in demand.

There were 475,000 patients in nursing homes in April 2001, which was the approximately the same level as the previous year. Encouraging providers to open new homes and increase capacity will require an increase in the fees paid.

On the basis of current rates of closure and forecast demand for places, the care home sector will reach saturation point where demand will outstrip places by 2006.

As discussed above, demographics are a major budget pressure. By 2031, the Personal Social Services Research Unit (PSSRU) forecasts that in England and Wales, there will be a requirement for 620,000 care places. Currently there are 525,000 residential, nursing and long term NHS beds and places, and this number is declining rapidly. Without sustained, long term investment, to first stabilise, and then encourage investment in new places, the current difficulties in the NHS will recur and intensify with acute hospitals warehousing more and more older patients who will have nowhere else to go. Recent research indicates that the direct cost of delayed discharge to the NHS in the last year alone was around £88million.

Care home fees have been driven down, too far for too long, to ensure continuity of provision. Research has found that charitable homes are topping up state funded placements by £185million per annum. Whilst there are significant variations in the cost pressures across the country, there is only one conclusion: there must be an increase in rates paid to provide home owners with a rate of return on capital comparable to other businesses which would enable recruitment and retention of staff. The Local Government Association has concluded that there is a need for 15% increase in fee rates at an estimated annual cost of £270m. Attempts to limit the fee increase to new placements are likely to meet with only limited success as a way of controlling costs, as many home owners are simply refusing to accept placements and threatening to evict existing state funded residents.

By relating extra fee payments to quality through the introduction of locally agreed star rating schemes, increased fee rates could be targeted to reward quality care home providers and encourage investors into the market.

Prevention - `A little bit of help'

Access to low level home help and timely provision of aids, adaptations and equipment, can make a significant difference to the level of independence a person can enjoy and reduce the need for acute NHS intervention, therefore unlocking resources and reducing pressures on the NHS. By tightening eligibility criteria and increasing charges for these services, local authorities have restricted access to these services to those who require the greatest help. There is a clear false economy in this logic. Prevention in the community rather than cure in hospital is better for the person, for their family and for the NHS.

Investment in early low-level home support can prevent the need for more intensive support and reduce the likelihood of hospital admission. Examples of the types of scheme that could be made more widely available include:

Vulnerable Adults

In March 2000 the Government required local authorities and other agencies to draw-up adult protection strategies to tackle the abuse of vulnerable adults and elderly people. No new funds were earmarked to meet the extra costs of this work. As a direct result while many local authorities have drawn-up strategies they have not made any practical progress. Research by the charities Action on Elder Abuse and Counsel and Care suggests that the level of reported abuse represents just the tip of the iceberg. The implementation of practical multi-agency working to detect and prevent abuse requires funding.

Recruitment and retention

There are some 1.1 million people working in social care. With vacancy rates in excess of 20% and turnover rates of 16.9% for homecare workers, recruitment and retention of staff is a serious obstacle to delivering a high quality service. Staffing difficulties are hitting both public and independent sector care providers. This is already driving some of the fee increases for home and residential care discussed above and additionally the increased and unplanned reliance on agency staff in some parts of the country.

The LGA report Care to Stay? found that nearly two thirds of Social Services departments experience serious difficulty in recruiting social workers and almost half cannot find enough home care staff. There are particular problems in relation to vacancies amongst child protection staff, which in turn contribute to excessive caseloads. The position is particularly acute in London and the South East. The LGA findings are supported by the King's Fund report Future Imperfect? found that the staffing pressures had a direct impact on quality of service.

Funding Options

The following table sets a four-year programme of extra investment in social care. The figures are, in part, based on work by the Local Government Association.

Conclusions

This paper argues for new investment in social care to enable a shift in focus away from crisis management towards prevention.

The extra funds would enable children's services to be strengthened, producing better outcomes for individual children and long-term savings for the country.

Investment in services for adults and older people will ensure that the extra funds already devoted to the NHS deliver better results by preventing admissions to acute care in the first place and by offering a range of appropriate intermediate and long term care after discharge.

By moving back up stream the care system can foster independence and deliver better outcomes for children, older people and families. Investment in home and residential care services would help to unlock the extra investment already committed to the NHS.

Estimate for 1999/2000, the DoH does not routinely collect total client numbers.

Department of Health Personal Social Services - current expenditure in England 2001

Office for National Statistics. National population projections:1998-based. ONS series PP2 no. 22. TSO (London: 2000). Or see www.gad.gov.uk. Shaw C.1998-based national population projections for the United Kingdom and constituent countries. Population Trends 99 (2000), 4-12.

LGA Local authority Social Services budget survey, February 2002

NACAB 1997

Increased charges for services and tightened eligibility criteria

Children Protection Statistics NSPCC

DoH - Children who started to be looked after during the years ending 31 March 1996 to 2000 by reason for being looked after

Securing Our Future Health: Taking a Long Term View Derek Wanless 17^th April 2002 P3 para 1.12

Hansard 20 Nov 2001 : Column: 251W

DoH Community Care Statistics 2002: Home help/ home care services, England

Laing & Buisson `Care of Elderly People Market Survey 2001' 14^th Edition p26 Number of residential home places 1996 - 307,500, est 2001 - 297,600; Number of Nursing home places 1996 - 220,200 est 2001 - 196,800; Number of NHS long stay beds, 1996 - 47,900 est 2001 - 31,500

http://www.laingbuisson.co.uk/News/careofelderly2001.html

Community care statistics 2001 - Private Nursing Homes, Hospitals and Clinics

ibid

Paul Burstow MP, taken from Laing and Buisson Care of the Elderly Market Survey 2001,

PSSRU - Demand for Long Term Care: Projections of Long Term finance for elderly people 1998

House of Commons Library 22 February 2002

Cap in hand, report by Paul Burstow MP, January 2002

Department of Health, No Secrets: Guidance on Developing and Implementing Multi-Agency Policies and Procedures to Protect Vulnerable Adults from Abuse, LAC(2000)7

Training Organisation for Personal Social Services (TOPSS)

LGA Service Working Group for Personal Social Services Feb 2002

Care to Stay? Report on an Action Research project on Human Resource Management Strategies in Personal Social Services, published 17^th October 2001

Figures for 2003/04 to 2005/06 are the additional expenditure in each year.

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