We need to do better on social care
Jeremy Hunt outlines the 7 key principles that will guide the Government's thinking ahead of the social care green paper, to be published later in 2018
"Grow old along with me! The best is yet to be."
The famously optimistic line by Robert Browning might seem out of place to many worried about how we will cope with an ageing population
In modern-day Britain, one of the most developed countries on the planet, our aspiration should be to prove those worries wrong. Because how we care for our most vulnerable citizens is the true litmus test of whether we are a civilised society – not only the care for older people but for younger disabled people who are living much longer.
Progress has been made: the Better Care Fund is transforming the way councils and the NHS work together to treat the whole person: nearly 7 in 10 service users were extremely or very satisfied with their care and support over the last 3 years, and 81% of adult social care providers are rated as good or outstanding. Spending will rise by 9% this year, the number of care home agencies is up 55% since 2010, and we recently set out a new package of measures to protect care home residents from unfair practices.
But today I want to be honest about how well we are meeting that litmus test. In truth, not well enough.
Many families find it incredibly hard to access the care they want with or without means-tested support from the state.
Many people employed in the system find themselves working too hard as they struggle with fragmented services coming under unprecedented pressure.
The CQC has itself expressed serious concerns about the state of the adult social care market and the risks of provider exit.
And that pressure is feeding through to the NHS with A&Es becoming overcrowded because hospitals find themselves unable to discharge patients who cannot access social care support packages.
Behind these systemic issues sit many ordinary human beings in a great deal of distress. Families coming to terms with a relative with dementia. Older people living on their own who won’t admit they are lonely. Care home residents with clinical depression, as we know happens in 4 in 10 cases.
So let’s be brutally honest. In a country that prides itself on kindness, neighbourliness and respect this does not sit easily, and we need to do better.
Now no-one could accuse this or any government of not talking about the issue. In the past 20 years there have been 5 Green or White Papers, numerous policy papers, and 4 independent reviews into social care. So it would not be unreasonable to expect scepticism about yet another one this year - and as the new Health and Social Care Secretary I do rather feel the weight of stalled reform programmes on my shoulders.
So in order to get things right this time I want to outline the 7 key principles that will guide our thinking ahead of the Green Paper. And in doing so I wish to pay tribute to the work done by Damian Green, my predecessor, on whose thoughtful foundations much of our thinking has developed.
The first key principle relates to the quality of care. 81% of adult social care providers are good or outstanding according to the CQC – testament to many hardworking and committed professionals working in care to whom we owe a huge debt of gratitude.
But still too many people experience care that is not of the quality we would all want for our own mum or dad. They describe a daily visit from a rotating cast of care workers, perhaps as brief as 15 minutes, with barely time to get help washing or getting dressed and no time to build the friendly relationships that are only possible with proper continuity of care.
And then, despite some improvements, we also still get cases of demonstrable neglect, such as a few weeks ago when a worker at a care home in Norwich was jailed for bullying vulnerable patients, including humiliating a resident with incontinence problems in front of others.
So my first of the 7 principles will be that we need a relentless and unswerving focus on providing the highest standards of care – whatever a person’s age or condition. This means a commitment to tackle poor care with minimum standards enforced throughout the system so that those using social care services are always kept safe and treated with the highest standards of dignity and compassion – or as our Chief Inspector for Social Care puts it, that all provision passes the “good enough for my mum” test.
Part of this will be tackling the unacceptable variations in quality and outcomes between different services and different parts of the country.
How can it be, for example, that, according to the NHS atlas of variation, there is around a 90-fold difference in the over 75s’ rates of admission to hospital from care homes or nursing homes between the highest and lowest performing local authority areas?
Over the last 5 years enhanced CQC inspections have been central to the journey of improvement that the NHS has been on. And thanks to the superb leadership of Andrea Sutcliffe and her team, those principles have been extended to the social care provider sector. No longer do we worry in the same way as before that abuses in a small minority of cases will go undetected for long periods and we see demonstrable improvements in the majority of cases when people are inspected a second time round.
But the recent local systems reviews conducted by the CQC have demonstrated that an independent approach to reviewing commissioning as well as provision can also be a powerful force for good. These reviews have highlighted variation in performance between local authorities across a range of measures, including how the local authority commissions care from local providers.
So we now need to ask whether the time is right to expand that approach, and one of the questions the Green Paper will pose is whether we can build on the learning from the introduction of independent Ofsted-style ratings for providers to spread best practice to commissioners as well.
2. Whole-person integrated care
Secondly we know that right now, despite many warm words, if you have complex needs our current health and social care system can be confusing and fragmented.
An 85 year old living alone with multiple conditions such as diabetes and early stage dementia often faces a bewildering range of services and organisations.
And the risk is that too often an individual and their family are passed from pillar to post, giving the same information repeatedly without receiving joined up, personalised care that makes them feel like a valued human being and not just another task on someone else’s to do list.
So my second key principle is the full integration of health and social care centred around the person. We know when this happens people stay longer at home, healthier, more independent and needing fewer hospital services.
There are many good examples of progress from around the country:
• In Waltham Forest they have introduced a managed network of care and support to meet the needs of local residents through individually selected services – and seen emergency admissions reduced by a fifth during 2015/16.
• In Leeds an integrated care record is now used by over 5,000 health and social care professionals so hospitals arrange faster discharges with care packages put in place more quickly.
• The Better Care Fund, too, has incentivised local areas to work more closely together, and many now have mature systems in place to bring together health and care services around the needs of their older populations.
But the key to this progress is that users of the social care system should have just one plan covering all their health and social care needs based on a joint assessment by both systems. So today I can announce new pilots in Gloucestershire, Lincolnshire and Nottinghamshire which will mean that over the next 2 years every single person accessing adult social care will be given a joint health and social care assessment and - critically - a joint health and care and support plan, where needed.
Why does this matter? Because integration must never be a bureaucratic exercise that makes life easier for professionals but makes no difference to people using the services. We will fail if we only join up the structures – we have to focus relentlessly on joining up the actual care experienced by vulnerable adults and service users on the ground - and these 3 pilots are intended to be trail-blazers for how to get this right.
My third critical principle is control. What matters to individuals and families is the ability to direct the care they receive and autonomy to lead the lives they want.
Personalisation isn’t new, and there is a strong consensus that it is the right path to follow, but progress has often been slower for older people than for working age adults with disabilities. Whilst over 90% of older people receive some type of self-directed support, only around 1 in 6 take it as a direct payment with take-up stubbornly low for older people.
Yet we know that the greater control people have over their care, the better their outcomes and the lower the cost. I heard the story of Malcolm Royle, who had dementia, from his son Colin. His personal budget meant that Malcolm no longer had to go to the day centre 8 to 5, but could have regular carers when he needed them. He got back control of his life - and we need to help everyone do this if they have the mental and physical capacity to do so.
So I want to turbo-charge progress on integrated health and care budgets, making them the norm and not the exception when people need ongoing support.
And today I can announce that we will be consulting on Personal Health Budgets, in order to achieve better integration for those with the greatest ongoing social care needs as well as health needs.
And as part of that I commit that over the next 2 years in Gloucestershire, Lincolnshire and Nottinghamshire - our 3 pilot areas - every single person with a joint care plan will also be offered an integrated health and care personal budget.
Control also means transparency and access to reliable information. Where individuals and families have the necessary information to make informed choices, it usually drives quality up. Yet the truth, as set out in a comprehensive report by the Competition and Markets Authority last year, is that the current social care market is anything but transparent. We also need to make sure that anyone who needs to can get the right information to make a meaningful comparison between services so that they end up with a fair and straight deal on their choice of care provider. This isn’t just fairer, it will also spur quality and innovation in the sector.
My fourth principle is to respect and nurture the social care workforce.
People who work in care homes, who do home visits, who look after people with care needs with kindness and love in every street in every town – these are our society’s modern-day heroes. Often highly skilled, they are typically also the lowest paid.
I am deeply proud that the introduction of the National Living Wage means that the average salary for a care worker in the independent sector has gone up by 4%, with those on the minimum wage seeing a pay rise of up to £2,000 since 2015.
But to attract more people into this sector, financial support must be matched with recognition of the value of this vital work and action on the wider set of challenges facing the workforce.
Today is World Social Work Day. So it is right to acknowledge that as a society we have ascribed too little value to these vital caring roles: yet the quality of care our parents get in their final years is as important as the quality of education our children get at the start of their lives.
So it is time to do more to promote social care as a career of choice and to ensure there are better opportunities for progression into areas like nursing which span both the health and social care sectors. And we need coherent workforce planning that is better aligned with that now being undertaken by the NHS. Alongside social workers, occupational therapists and nurses in social care we have many care workers who could benefit or be inspired by new progression ladders similar to those that are being developed in the NHS including roles such as associate nurses and nurse degree apprenticeships. These must be as available to those working in social care as in the NHS.
We have many registered professionals including social workers, occupational therapists and nurses in social care; and many more care workers and other unregistered professions. We need to ensure we have enough people within all of these skilled roles to support people to live the best possible lives. That means making sure that the new routes in to professions that we have developed for those working in the NHS, and the new roles such as nurse associates, also work for those wanting to build their careers in social care.
We need to recognise that people move between the NHS and social care systems - and will do more so as the 2 systems join up. So part of our thinking must be to think about health and care workforce issues in a joined up way. I can therefore confirm today that later this year we will not now be publishing an ‘NHS 10 year workforce strategy’ – it will be an ‘NHS and social care 10 year workforce strategy’ with the needs of both sectors considered together and fully aligned.
5. Supporting families and carers
Ronald Reagan famously quipped that “the nearest thing to eternal life we’ll ever see is a government programme.” A big danger in this debate is to see it purely as a government solution.
So my fifth principle is to make the needs of carers central to our new social care strategy.
Of course we need to foster the deep, innate and human responsibility we all feel to look after our loved ones, families and friends. But we should never take it for granted.
If we can make it simpler to look after a loved one, if we can make it easier to juggle working and caring responsibilities, if we can encourage volunteering – whether by more flexible working, better employer support or harnessing new technologies, then that is what we should do.
Over the past months we have been listening to the views of carers so ahead of the Green Paper we will publish an action plan to support them.
And alongside support for carers, as a society we also must tackle the epidemic of loneliness. It is truly a scandal that over 30% of people in Britain over the age of 65 say that television is their main form of company. So the appointment of Tracey Crouch as Minister for Loneliness is a welcome sign of the Prime Minister’s personal determination to address this issue, and we will work with her as we develop the Green Paper to address the underlying causes of loneliness by building an active and creative partnership between the state, individuals and wider civil society.
6. A sustainable funding model for social care supported by a diverse, vibrant and stable market.
Person-centred care means nothing if the individual’s choice and control is undermined by a lack of high-quality services to provide the support they need. Too often we hear of people unable to find the care they want, or of services which are only available in some places but just don’t exist in others.
We have to make sure that we have a vibrant and diverse base of care services for people to draw on. So the sixth principle running through our Green Paper will be the question of how we ensure a sustainable financial system for care, delivering a stable and vibrant market which delivers cost-effective, quality services for all including the debate we need to have with the public on the challenges of sourcing additional social care funding.
We should not assume that the best long term answer will be necessarily the same for different age cohorts. There may be changes that are equitable and achievable for younger people that would not be either of those for the generation approaching retirement. And part of the outcome of this process must be much greater public understanding of where the costs – often inappropriately – currently lie both for the state and individuals in every age cohort.
We also know the economics of the publicly funded social care market are highly fragile so we need to transform and evolve our models of care.
We will therefore look at how the government can prime innovation in the market, develop the evidence for new models and services, and encourage new models of care provision to expand at scale.
This will specifically include looking at the role of housing, including how we can replicate the very best models that combine a home environment with quality care and how we can better support people through well-designed aids and adaptations.
We must also recognise the potentially transformative role of new technology. We British are good at innovation, although sometimes less good at its application: so let’s see the brightest and best new ideas put into action to help us tackle the challenges we face and that will help us stay at home independently for longer.
Which is why the Ageing Grand Challenge announced as part of the Industrial Strategy needs to play a definitive role. Only last week the Government announced a new £98 million innovation fund to support healthy ageing. This funding will aim to catalyse public-private investment in technologies and innovations so that we don’t just invent great ideas here, we see them taken up throughout our system.
Going forwards, I will be working closely with other government departments, industry, civil society, academia and local government to ensure we make the most of the opportunities that the Industrial Strategy presents.
A more vibrant and diverse market offer will give people greater choice and more effective support. But it is also vital because if we do nothing to support people’s needs more creatively or efficiently, the cost of simply delivering these services today will double in a decade.
And of course we must make sure there is a long term financially sustainable approach to funding the whole system.
Resolving this will take time. But that must not be an excuse to put off necessary reforms. Nor must it delay the debate we need to have with the public about where the funding for social care in the future should come from – so the Green Paper will jump-start that debate.
7. Security for all
The final principle, which lies at the heart of this debate, is the question of security.
We are proud that 70 years ago this country made a big statement of our values when we established the National Health Service. It is, to this day, the most powerful expression of what we believe in as a society, the central idea that no-one – rich or poor, young or old – should have to worry about affording good healthcare.
But this year is also social care’s 70th birthday. The National Assistance Act that abolished the Poor Law and created many of the core elements of the modern social care system came into effect on the same day as the NHS Act.
The National Assistance Act established a related but different principle: that of shared responsibility for care. Whilst the State has always accepted – and continues to accept – its duty to provide decent care for those unable to afford it – notably for those born with a disability or developing a care and support need early in life - our system has also reflected the principle of personal responsibility for care by individuals and families.
And the principle of shared responsibility continues to be right and people should continue to expect to contribute to their care in the future as they prepare for later life – but we are clear that there has to be a partnership between the state and individuals.
But the way our current charging system operates is far from fair. This is particularly true for families faced with the randomness and unpredictability of care, and the punitive consequences that can come from developing certain conditions over others.
If you develop dementia and require long-term residential care, you are likely to have to use a significant chunk of your savings and the equity in your home to pay for that care. But if you require long-term treatment for cancer you won’t find anything like the same cost.
So people’s financial wellbeing in old age ends up defined less by their industry and service during their working lives, and more by the lottery of which illness they get. We therefore need a system that includes an element of risk-pooling and, as the Prime Minister promised in the election campaign, we will bring forward ideas as to how to do this alongside their potential costs in the Green Paper.
The Green Paper will be published before the summer and will be framed by thinking on the 7 principles that I have set out today:
• quality and safety embedded in service provision
• whole-person, integrated care with the NHS and social care systems operating as one
• the highest possible control given to those receiving support
• a valued workforce
• better practical support for families and carers
• a sustainable funding model for social care supported by a diverse, vibrant and stable market
• greater security for all – for those born or developing a care need early in life and for those entering old age who do not know what their future care needs may be
Innovation is going to be central to all of these principles: we will not succeed unless the changes we establish embrace the changes in technology and medicine that are profoundly reshaping our world.
By reforming the system in line with these principles everyone – whatever their age – can be confident in our care and support system. Confident that they will have control, confident that they will have quality care and confident that they will get the support they need from wider society.
Let me finish by quoting the words of Fauja Singh, who at a mere 100 years of age became the oldest person ever to complete a marathon: “Anything worth doing”, he said, “is going to be difficult.”
The path to a long-term settlement for social care, built around a strong social contract, has been equally long and arduous, and there will no doubt be further twists and turns.
But Britain has a proud pedigree in establishing one of the first comprehensive healthcare systems in the world. Our innate sense of decency, kindness and common humanity will also drive us to the right solution for social care as it has for health.