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Alarm bells ringing: the adult care crisis

06 December 2019

Successive governments have failed to stop the rot in the adult social care system, and it is now approaching crisis point. As we go to the polls, journalist Linsey Wynton explores what’s at fault, what’s needed and how urgently.

Families of all ages are gathering together this festive season, yet they have genuine reasons to be concerned for their futures. There are more than 12 million people aged 65 or above in the UK (ONS, 2018), yet around one in seven do not have all their care needs met (Age UK, 2019a).

It’s great that we’re living longer: by 2030, one in five people in the UK will be aged 65 or over and the 85+ age group is the fastest growing section of the population, set to double to 3.2 million by 2041 (Age UK, 2019a). Yet the needs of older adults have been neglected by the austerity agenda and the Conservative government’s broken promise of a green paper for adult social care made in spring 2017 (Local Government Association (LGA), 2019). It doesn’t start and stop there: the issue has been neglected for two decades by successive governments (Abrahams et al, 2019; Thorlby et al, 2018). And it’s England where the situation has been most dire.

Since 1999 there have been 12 reviews of funding and reform of adult social care in England but no sustainable solution (Quilter-Pinner, 2019; Thorlby et al, 2018). In June 2019, 11 experts who had advised the government on the proposed social care green paper, wrote to The Telegraph saying: ‘We are united in our despair at the failure of governments for the last 20 years to deal with the critically important issue of the funding of social care. The system is underfunded, unsustainable and unfair’ (Abrahams et al, 2019).

In his inaugural speech as prime minister in July 2019, Boris Johnson said: ‘My job is to protect you or your parents or grandparents from the fear of having to sell your home to pay for the costs of care… We will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve,’ (BBC, 2019).

The government allocated an extra £1bn for social care for children and adults in England in its September spending review (Anandaciva, 2019). But experts aren’t convinced. ‘This is a sticking plaster to keep it going for the year – not enough for a system on the brink of collapse,’ says Daisy Cooney, health and care policy manager at Age UK.

Amid the political turmoil and Brexit chaos, adult social care experts say reform is ‘like a mirage forever on the horizon’ (LGA, 2019) and describe the green paper as ‘elusive as a unicorn’ (LGA, 2019). With a general election almost upon us, whichever party wins, experts are unanimous: this matter needs urgent attention.

Just as this journal was due to go to press, Secretary of State for Health and Social Care Matt Hancock wrote about the ‘long-term problem’ in the Daily Mail (Hancock, 2019). He revealed a pledge of £1bn per year in extra funding for social care over the next five years, and a commitment to pursuing a cross-party consensus to address the challenges if the Conservatives win the election. These promises were then set out in the Conservative party manifesto (2019a).

 

The current emergency

Back to the reality now and in England, adult social care faces a £3.6bn funding gap by 2025 just to maintain existing standards of care (LGA, 2018). Services are provided by local authorities, which have suffered a 50% real-term reduction in government funding since 2010 (LGA, 2019).

‘Nearly half of all requests made for social care in 2018-19 were not met with care services,’ says Daisy. People received no care, were signposted to generic services or sadly died while waiting.’

Spending on adult social care in England is £700m below the level of 2010-11 (LGA, 2019). Unsurprisingly, one in six adults in the UK now provides unpaid care (Age UK, 2019b). The House of Lords Economic Affairs Committee recently said that government should immediately invest £8bn in adult social care in England, an estimate that the Health Foundation and The King’s Fund calculate is required to restore quality and access to 2009-10 levels (House of Lords, 2019).

Meanwhile, Harry Quilter-Pinner, senior research fellow at the Institute of Public Policy Reform (IPPR), said: ‘Fewer people are getting access to the care they need as result of swingeing budget cuts. Instead, people have to rely on family and friends, paying for it themselves or going without. One in 10 people now face ‘catastrophic care costs’ of more than £100,000 – many having to sell their family homes to find this funding. And, all too often when people do access care, it is not at a standard we would expect’ (Quilter-Pinner, 2019).

Yet only 12% of over-55s in the UK have set aside money for future care costs (Pearl, 2018) and the majority think social care is provided by the NHS and therefore free (LGA, 2019).

 

What needs to happen?

Free care for all

The Labour party has pledged, if they win the election, that they will offer free personal care to all UK adults, borrowing £150bn for a social care fund for schools, hospitals, care homes and council housing (ITV, 2019; Labour, 2019).

While the Liberal Democrats (2019) promise to pool health and social care budgets, put a penny on income tax to raise £7bn a year, and limit the amount the elderly pay for care.

Personal and nursing care is currently free for older adults in Scotland (at home and in nursing homes, as well as in care homes), as is care provided in Wales by nurses in nursing homes, but not in England or Northern Ireland (Age Scotland, 2019; Quilter-Pinner and Hochlaf, 2019; Age Cymru, 2018; Shepherd, 2018). Think tanks including the IPPR have argued for free personal care for older adults in England costing an estimated £19bn by 2030 (Quilter-Pinner and Hochlaf, 2019).

Polling by YouGov for Independent Age found 74% of adults in England support free personal care for all who need it, and 69% would be willing to pay more tax so provide it (Independent Age, 2018).

The Conservatives have pledged to boost the NHS budget by £33.9bn by 2023-4 (Conservatives, 2019b).

Daisy says more funding must be available for preventative care and unpaid carers: ‘As funding has been cut, the level of need a person has before getting a care package has increased significantly.’

Dr Jane Douglas, Queen’s nurse and chief executive of Queen’s House care home in the Scottish Borders, says: ‘Care cannot be done on a shoestring – it needs investment.’ On what needs to happen across the UK in the future with an ageing population, she continues: ‘If we can invest in supporting people at home and in care homes we will prevent people going to hospital, which will save a fortune.’

George Coxon, mental health nurse, social care consultant and owner of two Devon care homes, agrees. ‘We have a population of older people who are likely to have catastrophic hospital admissions. Acute hospitals absorb the majority of the £130bn NHS budget, while social care gets £22bn and 40% of people in hospital beds who are medically fit for discharge are delayed because of the transfer of care.  

‘If we do not make sure older people have choices about care options, hospitals will become industrial silos for older people.’

‘If we do not make sure older people have choices about care options, hospitals will become industrial silos for older people’

An end to care deserts

In the absence of a recent government green paper, the LGA published its own in 2018, even offering to facilitate cross-party talks. A year later it published the Future of adult social care – one year on, reiterating calls for urgent government action, and showing adult social care employs 1.5 million people and contributes £46bn to the UK economy (LGA, 2019).

The LGA green paper pressed for an end to ‘care deserts’ – UK postcodes with no care available for older people, such as Hull and Totnes where there are no nursing home beds (Incisive Health, 2019).

Daisy says: ‘In some parts of the country it doesn’t matter if you are self-funded or you are relying on your local authority to pay for your care – reliable care is not available. This puts immense pressure financially, emotionally and physically on families.’

Age UK hears from families struggling to drive hundreds of miles to care for loved ones, sometimes daily, and from rising numbers of people in their 80s caring full-time for spouses and siblings also in their 80s.

Meanwhile, Jane adds: ‘A lot of people come to the Scottish Borders to retire and we also have an ageing workforce, so we don’t have the people to look after the ageing population.’ So even though care is free in Scotland, moving forward, more needs to be done to recruit, train and retain staff there, as in the rest of the UK. Better recruitment and retention The LGA green paper also demanded better pay and training for care workers (LGA, 2019). Currently many home-care workers in England receive less than minimum wage as they are not paid to travel between clients (Albert, 2019). George says: ‘We have a perfect storm – people are living longer with complex needs and we have massive problems with the workforce, with 43,000 NHS nurse vacancies and 110,000 social care vacancies.’

Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute (QNI) and former health visitor, says: ‘Our politicians need to understand that health and social care must be addressed together. The shortage of nurses in adult social care needs a higher profile. Recruitment and retention initiatives must be for all sectors. It’s disappointing that the CPD funds for nurses of £1000 each is only for NHS nurses.’ Of course, this means nurses working in care homes and across the social care sector are not included.

The LGA green paper also showed that adequate measures have not been implemented to prevent a ‘Brexodus’ of care staff if and when we leave the EU, as high numbers of nursing home nurses are EU nationals (LGA, 2019). Crystal adds: ‘If we leave the EU, we will create an even bigger gap in nursing and social care in future years.’

Because of the lack of nurse training and recruitment, some nursing homes have had to de-register and become care homes, while some parts of England are unable to attract skilled workers, putting social care services at risk of collapse (Incisive Health, 2019).

Meanwhile NHS district nurse (DN) numbers have been reduced by up to 45% since 2010. A funding gap in the Health Education England (HEE) budget for DNs could mean that none enter the NHS in 2021 (Incisive Health, 2019). Yet currently the NHS health careers website says DN patients will ‘often be elderly’ and that ‘DNs play a vital role in keeping hospital admissions and readmissions to a minimum’ (HEE, 2019).

In 2019, the government launched Everyday is Different, promoting adult social care jobs. But Stephen Wilson, co-founder and CEO of care recruiter Novacare, called for a speeding-up of checks such as protection of vulnerable groups, initiatives to address the shortage of male care applicants, and more funding for training.

He says: ‘The constant demands from regulators, councils, social work and hospital teams has created a self-perpetuating problem of poor retention, which places ever more pressure on recruiters.’

Although care staff in Scotland receive the real living wage (Scottish Government, 2019), Jane says care must be made appealing to young people through clear career structures, such as opportunities to do Open University nurse training. She says: ‘People coming into care homes now are much frailer than they were 10 years ago and we need a workforce skilled to meet the needs of people with complex conditions.’

‘In some parts of the country it doesn’t matter if you’re self-funded or relying on your local authority to pay for your care – reliable care is not available’ 

The District nurse perspective

Liz Alderton, DN team lead, says: ‘We have always seen older people on our caseload, but in the past we had more time to chat. Now we are phenomenally busy with people with everything from complex wounds, chemotherapy or nasogastric tubes.

‘We recommend families struggling with the care of an elderly relative to get an assessment by social services. People’s main concern is getting through on the phone. Plus the assessments are quite rigorous.

‘The funding side of care is complicated and there needs to be a simple guide for families and professionals.

‘We know of hundreds of people selflessly caring for loved ones such as elderly spouses and grandparents while also working. Two generations ago, when families lived closer to one another, it was easier.

‘People tell us they cannot afford care. Sadly we know of elderly people we visit who use foodbanks.

‘When older people get a visit from a carer, it is usually a couple of times a day – in the morning to get washed and dressed and in the evening for their meal. Most people want to be up and ready by 9am or 10am and have their dinner about 5pm. But a shortage of carers means we hear of people who get a first visit at lunchtime and their last visit at 3pm. Carers need to be paid more and offered more training opportunities.’

 

How can CPs best support families?

Although a smaller number of HVs now work directly with older adults, many see families with young children – who make up the ‘sandwich generation’ – caring for older family members as well.

Experts advise CPs working with older adults (or with families concerned about older adults) to:

  • Encourage families to talk about concerns when older people reveal difficulties, such as forgetting medicines, frailty, or signs of dementia.
  • Be proactive. Don’t wait until the person has had a hospital admission – think about what you can put in place to prevent that.
  • Suggest families know the good local care homes – and that they can even volunteer there, perhaps after retirement.
    George (mental health nurse, consultant and care home owner)
     
  • Identify when a person’s care needs have changed and ensure families talk to the local authority about having their needs assessed: for example, if they have been in hospital for a fall, lack of hydration or poor nutrition.
  • Understand hyperlocalised care – if the only care home with beds is 50 miles away, what options might there befor domiciliary care?
    Daisy (Age UK)
     
  • Ask the local authority for lists of all services approved by the Care Quality Commission, including residential care and home-care.
  • If a person is considering residential care, use a capacity tracker software programme for healthcare professionals to flag up bed capacity.
    Crystal (QNI)

 

Home-care vs care home vs hopsital

George says: ‘In seven in 10 cases we see there’s been a hospital admission because the older person has fallen over and it’s been discovered that they have long-term conditions.

‘The key principle is to keep people out of hospital. Older people do not do well in hospital. Wards are brightly lit and noisy and there are infection risks.’

Jane sayss: ‘In Scotland, the model is about supporting people to remain at home for as long as possible. But some people prefer a care home because they need the company. If you live in your own home, you might only get a visit twice a day and if you have no relatives nearby, you might get lonely. Being in a care home can change that.’

In fact, Jane suggests older adults considering a care home should come to see it first. ‘Meet staff and residents and think “How would I feel about living here?” and “What would that give me that I am not getting at home?”’ says Jane. ‘Most people end up in a care home following a hospital admission and never go home again. The transition is better when a person makes that decision themself.’

How will this social care emergency be solved? Before the party manifestos were released, experts were united in highlighting the need for awkward, transparent conversations about the costs of adult social care funding to society and individuals (House of Lords, 2019; Chirgwin, 2019). And that it needs to be a top priority for the new government.    


The current figures:


Care costs across the UK

Scotland:

  • Personal and nursing care is free for all older people, both in their own home and in a nursing/ care home.
  • If you have savings and assets of more than £17,500 you will need to pay towards nursing/ care home accommodation.

Wales:

  • If you have savings and assets of more than £40,000 you will need to pay all your care/nursing home costs. All nursing/care home residents must contribute through their pension.
  • Those requiring a nursing home get nursing costs covered by the NHS.
  • The maximum charge for care in your own home is £90 per week.

England and Northern Ireland:

  • If you have savings and assets of less than £14,250 you qualify for local authority-funded support. Those with assets of less than £23,250 receive partial funding.
  • For home-care, the value of a person’s home is not taken into account, but it is if a person needs to go into a nursing/care home.
  • In England, contributions are also taken from people’s income and vary countrywide. 

References:

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Age Cymru. (2019) Paying for care and support at home in Wales. See: https://www.ageuk.org.uk/globalassets/age-cymru/documents/information-guides-and-factsheets/fs46w.pdf (accessed 14 November 2019).

Age Cymru. (2018) Paying for a permanent care home placement in Wales. See: https://www.ageuk.org.uk/Global/Age-Cymru/Factsheets%20and%20information%20guides/FS10w.pdf?dtrk=true (accessed 14 November 2019).

Age Scotland. (2019) Care home guide: funding. See: https://www.ageuk.org.uk/globalassets/age-scotland/documents/ia---factsheets/care/care-5-care-home-guide---funding-may-19.pdf (accessed 14 November 2019).

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Age UK. (2019b) Getting carers connected: research summary carers week 2019. See: https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/care--support/cw19_research_report_final.pdf (accessed 14 November 2019).

Age UK. (2019c) In England 74,000 older people have died or will die waiting for care between the 2017 and 2019 General Elections. See: ageuk.org.uk/latest-press/articles/2019/november/in-england-74000-older-people-have-died-or-will-die-waiting-for-care-between-the-2017-and-2019-general-elections/ (accessedd 25 November 2019).

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