Few would dispute that adult social care in the UK has reached, and probably passed, crisis point. As the population ages, funding shortages bite, and the industry struggles with impossibly high staff turnover, it has become increasingly clear that the status-quo is skating on the thinnest of thin ice.
Yet when it comes to what can be done in response, the focus tends to narrow on two issues: the role of state intervention, and how much money is needed to plug the long-acknowledged funding gap. Recent experience shows that there are no easy answers on either front, while the Government’s response so far has been more presentational than progress-oriented. Social care might have been added to the Department of Health’s nameplate, but the reality is that the green paper on social care, first promised last November, will now be delayed until the coming autumn.
And, having committed to an overall funding interest for the NHS, none of the annual £20bn increase will be used to support social care. Moreover, the appetite for bold political measures may have been curbed by the ‘dementia tax’ debacle, which showed the obstacles to building public permission for raising more funds for care in later life.
If those working in, and dependent on, social care expect the Government to ride to the rescue, they will be waiting a long time, for policy and public funding that threatens to be deeply insufficient to meet the need.
Instead the industry needs to look to itself. Because even if the Treasury could rustle up the money to fill the funding gap (£2.5bn a year by 2020, according to the King’s Fund), that would not solve the problem. Even worse than the system being underfunded is the reality that it is flawed by design: a model of care provision that is sparking a recruitment and retention crisis, and which fails to take advantage of technology to improve patient outcomes and cut costs in parallel.
More money may be needed, but alone it will not heal all ills. That can only happen by fundamentally reforming how care is provided, and a new approach that helps us make more of the funding that does exist. The social care crisis is not just one of funding, but recruitment, patient and carer experiences, and health outcomes. Only when the industry embraces the need for change that encompasses all of these challenges, can we hope for meaningful reform and progress. That will require focus on two issues beyond funding: the organisation and administration of social care, and how frontline care is delivered in practice.
Changing how care is organised
No-one takes a job as a social carer without good intentions to help people and make a difference. But carers are working in a system that makes it almost impossible to be a trusted and personal support system that patients can rely on. As the Guardian reported in 2016, a typical day for a carer might include over 20 house calls in 12 hours, including 20 miles of driving, as part of a rota that allows just two days off every fortnight. Many caring jobs are on zero-hour contracts, while the average salary for a frontline, full-time carer is £14,800.
Too many carers are being treated more like contract cleaners than the care professionals they are, with the wellbeing of hundreds of thousands of people in their hands. And the negative impact on care-givers and patients is alike is clear to see.
For carers it has contributed to a crisis in recruitment and staff turnover. An average of 928 carers leave the profession every single day, which added up to 27.3% of the entire workforce over the 2015/6 financial year. In parallel, a report by the Communities and Local Government select committee has found that 48% of new caregivers leave within a year of starting. This is clearly unsustainable in a sector where over 84,000 jobs are already vacant. But it is hardly surprising given the low pay, demanding schedule and near impossibility of delivering meaningful care through tightly packed
Nor can anyone be shocked that patient satisfaction in social care is cratering: just 23% were ‘very’ or ‘quite’ satisfied with social care in 2017, down sharply from its 2007 level of 43%, and well below the 57% for the NHS as a whole. That surely reflects the demise of a strong bond between patient and carer, where the average experience can amount to four different visits a day from four different carers, lasting just 15 minutes apiece.
In other words, the system is one that serves neither carers nor patients, and has diluted the essential bond between them. The only way to reverse the damage is to go back to first principles: restoring the direct relationships between care-givers and those they support. At HomeTouch, this is something we are doing through our online platform, which matches families with carers.
Another model we admire is the Dutch Buurtzorg (neighbourhood care) model, where carers team up to look after groups of patients in a local area, organising independently and with only light-touch administration.
That principle, allied to the power of digital platforms to connect caring expertise with patient needs, can give power back to families and carers alike, breaking out of the bureaucratic and impersonal system that many currently experience. And only then can we start to think about reversing the crisis in recruitment and retention that is threatening to bring social care to its knees.
Changing how care is delivered
It is not just the administration of care that is undermining its efficiency and effectiveness. Equally, if not more, important is what the sector currently considers to be meaningful care giving.
The ‘time and task’ model imposed on many carers, where they are required to cram a list of tasks into a short home-visit, leaves little space for responsive and empathetic care giving, as well as demoralising carers with an unsustainable workload. In turn, the emphasis on developing new treatments draws attention and capital away from what can be done right now to help patients. The pharma industry has spent tens of billions on a putative cure for Alzheimer’s disease, while insufficient attention is given to what can be done to prevent and slow the progress for patients who cannot wait around for the miracle drug to arrive (not for another decade at least).
Instead, prevention should become the guiding principle around which social care is re-organised. When it comes to neurological conditions and diseases, for instance, rather than everyone shooting for the moon in search of a wonder pill, we should be focusing much more on what can be done to improve brain health right now. When up to a third of dementia cases could be prevented by simple lifestyle measures, from a more Mediterranean diet, to stable sleep patterns, exercise and ensuring your brain is challenged with new experiences, it is essential that we do more to help people help themselves.
According to the Alzheimer’s Society, just 2% of the population know what they can do to help prevent the onset of the disease. Under the Buurtzorg model, carers are required to provide this education and guidance as well as meeting immediate caring needs. A shift from the emphasis on immediate fire-fighting to long-term health coaching will allow patients to play a greater role in their own care, potentially reduce the number of care hours required, and acknowledge the severe limits of what can be achieved in a 15-30 minute home visit, which will remain the case regardless of how much new funding is found.
Alongside a greater focus on prevention must come increased and improved use of technology. From monitoring tools for those living alone, to care robots that can replace some functions of a human carer and help combat loneliness, and assistive technology that can support in areas from maintaining a regular sleep pattern to automating elements of cleaning, gardening and cooking, there is huge scope for technology to make care more efficient and support people to live an independent lifestyle for longer.
There will be reasonable fears that automation will make care less human; but really we should be looking for a balance, where technology releases carers from tasks that currently fill their time, allowing them to focus on areas where the human touch can make the most difference. In reality, technology can and should be good for patients and carers alike: providing an always-on support system for those who need it, while uplifting the role of caregivers to the point where the job regains the meaning and purpose that should be its core attraction in the first place.
Fix before you fund
The depth of the challenge facing the UK’s social care system means that we need to move past old assumptions and solutions, and look towards fundamental renewal of a broken model. There is much that can be fixed and improved without tapping a reluctant public purse for more funding. For some it will always be a heresy to suggest anything other than more money as the solution to our problems. But while the simplistic, headline-grabbing view will always warn that less expenditure means a lower quality service, in fact the opposite is possible.
Through re-organising how care is organised and delivered, focusing on stronger relationships, preventative care and patient empowerment, all allied to technological enhancements, we can create a social care system that performs better, costs less and achieves much more.