Andrew McCulloch and Matt Muijen
Social care in England is in crisis. We have often heard from the media or from practitioners during recent years that social care was experiencing serious challenges. All things are relative, some problems always exist, but this time the crisis is deep and far reaching. The Chancellor (finance minister) announced an extra £2bn in March but this will only have a limited impact. Following the UK general election in June would be an ideal time for a full strategic review.
We would suggest that we see the crisis in social care as a symptom of an overall systemic problem rather than an issue that can be “fixed” by simply topping up some resources. To address this requires a systems approach covering informal and formal care, housing, employment, communities and health care, including primary care and mental health services. It will require a raft of imaginative responses that involve maximising people’s ability to cope in their own homes, to avoid loneliness, to help each other, and to keep people out of hospital as far as is feasible. Perhaps these are some of the types of initiatives that might help:
- Financial and other incentives to encourage people to downsize and share accommodation either within or across generations;
- Using local resources – shops, pubs, churches, libraries – as hubs for inter-generational contact and for training and awareness raising;
- Developing local intelligence networks, involving shops, pubs, hairdressers and volunteers that can support vulnerable people using alert networks;
- Encouraging the delivery of greater amounts of healthcare at home, in residential care and in nursing care rather than hospital – at the moment we have only scratched the surface with what could be achieved;
- Developing better “step down” facilities from hospital to allow discharge that is not necessarily straight to home;
- Commissioning voluntary organisations, housing associations and the private sector to provide support for the transition from hospital to home using solution focused approaches that aim to fix the blockages whatever they are, rather than offering the fixed menu of services that currently passes for “personalisation”;
- Driving individual budgets further – also aimed at fixing these blockages – and allowing flexible budgets to be held by relatives and support agencies to spend on solutions;
- Developing an informal workforce that can befriend and support in simple ways, involving unemployed and retired people;
- Looking at shifts in transport policy that can enable these strategies to work, especially in rural communities;
- Looking again at the proposed solution in the Dilnot report to put a ceiling on the amount of money individuals must contribute to their own care and to require private or social insurance to cover the rest of the costs.
These are just examples and of course they mostly happen to some extent already, often led by voluntary efforts, by charities and by local partnerships. The problem is one of scale and the lack of strategic approach. Too often the focus is wrong. Whilst it is entirely understandable that the NHS is concerned with enabling discharge, and this is vitally important, it is not the heart of the issue. The core issue is the need for social structures, support and housing that have to be built around the person’s needs and preferences and that will enable them to transition from hospital when they need to. Social policy needs to be constructed to drive and incentivise behaviour that contributes rather than detracts from such structures. Then the NHS will benefit from a reduction in delayed discharges. You cannot treat delayed discharge as the disease when it is just a symptom!
What you can do is treat delayed discharge as the starting point for a wider analysis.
Immediate factors within the system that encourage delay include the precarious nature of the care homes industry of alternative independent sector providers, the fact that most social care costs are borne by individuals and families who are reluctant to deplete inheritance (and not necessarily for selfish reasons), the lack of staff to undertake assessments including NHS staff such as OTs, and the lack of availability of social care staff and resources to deliver the necessary support.
Wider structural factors that have a key role to play include the housing crisis, which is linked to another key issue – the fragmentation of families and communities. Erosion of centres for human contact like the closure of churches, post offices, pubs and shops in many communities, and depletion of public transport, all prevent support networks that can support community living from thriving. High rates of employment especially in low wage jobs or on zero hour contracts can also disrupt networks and whilst high rates of employment are desirable, low wages, long hours and uncertainty deplete people’s energy and capacity for informal care. The housing and labour market are also linked together with fragmentation because they are key reasons why families move apart seeking work and cheaper housing. As fragmentation proceeds loneliness becomes not just a driver of isolation and lack of support but also of ill health itself – both mental and physical, increasing pressure on public services even more. Thus a single event of delayed discharge can sit within a whole network of issues located both in health and social care and in wider socio-cultural and economic change.
The crisis in adult social care is very real and the £2bn is welcome, if insufficient on its own. We need to take a step back and ask ourselves what is the strategy that will dig us out of the hole we are in? At the moment actions are fragmented and incomplete, addressing symptoms. What we need in England, and in many other countries which face fiscal, demographic and socio-cultural issues that impact care, are new, pragmatic, and cost effective solutions that cross traditional sector boundaries. Of course, politicians, nationally and locally, are too intelligent to know that the problem can simply be solved by waiting. But there is a lack of analytical leadership and where it exists it is often focused on the mantra of prevention and early intervention. Whilst we have always been passionate advocates of such approaches they cannot surely impact quickly enough or at sufficient scale to overcome the massive demographic pressures and resource gaps we now face.
How then can we move ahead? We have to start addressing our problems fundamentally and rigorously, rather than just waiting for the system to fall over. And many of the solutions locally could be cheaper than simply feeding the beast more money to do more of the same. Some parts of the problem are much more intractable than others. So there seem to be two obvious steps –
- Firstly draw a map of the issues and how they interconnect. This needs to pay attention to the most powerful drivers creating the current raft of problems. All these are known through a range of work on health and social care, housing, social capital and community development, but that knowledge needs to be joined up;
- Secondly, we have to accept that although the analysis needs to be comprehensive, we cannot change everything immediately. Therefore the second step, both nationally and locally, is to identify the key leverage points that can make the greatest difference, assess them for feasibility and level of impact and start there. The rest will follow.
It is a great pity that much of the planning and strategic analytic capability at the centre has been lost over the years. However, that capacity does still exist in a variety of organisations across the country. There is no time like the present for some focused partnership work to develop new strategic solutions to the issues we face.