Social care in England

Brief history

Social care has long existed as an informal concept, through family and community support and charitable works. The earliest Act of Parliament to offer formal support was the Elizabethan Poor Law of 1601, which referred those in need of health or domestic care, housing, or employment to the care of their parish. This ‘care’ could include payments, food, apprenticeships, boarding or referral to a workhouse.

Social care became more formalised with the advent of social work in the 19th century. This shift is attributed to the end of the feudal system and the rise of industrialisation,and a more urbanized population which bought greater social deprivation. It also bought a decline in the support provided by family and close-knit communities as people became more mobile and moved to different areas for work. Social care was often provided by voluntary organisations, but some services were financed through health insurance contributions collected through mutually owned societies.

The development of social sciences such as psychology and sociology in the early 20th century bought social structures under further scrutiny and opened the way for social work to become an area of academic study and for a staff group to develop claims to be a profession.

When the Liberal UK Government came into power in 1906, the first means-tested pension came into force for people aged 70 and over. Further formal health and social care provision followed with the creation of the National Health Service in England (NHS) and the welfare state in England in the 1940s, making statutory health and social care free at the point of access for residents.

From this point a separation grew between policies to support income maintenance and those to support social care.

Areas of work

Social care in the modern context encompasses many areas of need, each with a level of specialist services. These can be broadly categorised as follows:

Adults – this includes support for older people, people with mental health problems, learning or physical disabilities, those with alcohol and substance misuse problems, the homeless, prevention of abuse or neglect, domestic abuse and associated support for families and carers

Children, young people and families – this includes preventative family support and child protection services, child placement, fostering, adoption, working with young offenders, children and young people who have learning or physical disabilities, or homeless, as well as support for families and carers.

Workforce – this includes the provision of resources, training and support for those working in social care.

Paying for social care

The majority of those receiving adult social care in England will be expected to pay for it if they are able to. Means-tested support is available from local authorities, but is targeted at those whose assets or income are not sufficient to pay for their care. Some local authorities may offer people a way to postpone paying their care costs through a deferred payment, though evidence suggests this is not currently universally available. Social care spending fell in real terms from £8.1bn (2005–06) to £6.3bn (2014–15), a fall of more than one-fifth, Age UK claims.

According to the UK Home Care Association councils should pay £16.70 an hour but on average pay £2 less. Councils blame the, 'squeeze on their finances by the government'. Carers have to prioritize the most important work and leave some jobs undone that their old or disabled clients need because there is insufficient time for everything. The Care Quality Commission claim cuts increase pressure on hospitals and reduce care quality.

Unless social care is properly funded, there remains a growing risk to the quality and safety of care, and the ability of services caring for our elderly and vulnerable to meet basic needs such as ensuring people are washed and dressed or helped out of bed. (Councillor Izzi Seccombe, of the Local Government Association

Targets for home care that should prevent patients staying in hospital unncessarily are in the majority of cases being missed. Campaigners condenmed the fact that the Chancellor's 2016 Autumn Statement did not include extra funds for social care. The Local Government Association spoke of an 'unadresseed crisis' while the NHS Confederation referred to a missed opportunity to reduce pressure on the NHS.

Conservative Lord Porter of the Local Government Association, asked the government to act urgently and fund social care so councils can protect services for elderly and vulnerable people. Services are at breaking point now and extra money at the end of the decade will not help now. Conservative, Stephen Dorrell also thinks the government is mistaken not to invest in social care and believes a small investment can bring significant improvemets. Porter also said, “New government money for social care is urgently needed. Without this, our most vulnerable continue to face an ever uncertain future where they might no longer receive the dignified care and support they deserve, such as help getting dressed or getting out and about, which is crucial to their independence and wellbeing.”

John McDonnell said in the House of Commons, “Tonight, many elderly people will remain trapped in their homes, isolated, and lacking the care they need because of continuing cuts to funding,” Dave Prentis of Unison said, “a growing number of elderly people are getting no care at all. Scrimping on social care is a huge false economy. Older people are often stranded in hospitals, unable to go home, using beds needed by other patients. This turns up the heat on our already overstretched NHS, which has also been forgotten about [in the Autumn Statement].”

Spending on social care fell by 9% in real terms during the five years to 2016. The government may consider allowing councils to raise council tax to pay for better social care. Critics consider this an inadequate response which will not raise enough cash to plug the funding gap for older and disabled people's care. It is feared in poorer areas where improved social care is most needed councils cannot raise the necessary funds. It is also feared social care people receive will depend further on the postcode lottery. How much care local authorities can pay for is uncertain as local authorities depend on government grants which were cut and business rates which are uncertain as well as council tax. The Local Government Association claims the change is too little and that belief is very widely shared. Conservative Sarah Wollaston said:

I'm not convinced that the local government settlement is new money, it brings some of it forward but doesn't grasp the seriousness of the shortfall. Rising unmet need for social care will not be resolved without genuine cross-party working to find a long-term solution to funding.

Chronically sick and disabled people may be forced to leave their homes and go into care homes if this saves money. Vulnerable people will lose their independence and be at risk of abuse. Care homes for the elderly are becoming insolvent in record numbers and are closing due to insufficient funding. Martin Green of Care England, alleges the care home sector is at a tipping point. Green said, “The government is abdicating responsibilities for social care to local authorities. I think it owes more to the protection of vulnerable politicians than it does to the protection of vulnerable adults. My view is that if you ask me who is to blame it is the government. The government should be delivering a very clear vision for what social care is, they should be giving clear expectations to citizens about what they should expect from the system and what they should expect to pay for and none of that is happening.”

The Local Government Association representing leaders of 370 English and Welsh authorities, estimates a £2.6bn funding shortfall by 2020, and fears some councils could be challenged in the high court for not providing a statutory minimum standard of care.

Lord Porter Conservative chair of the LGA, said services supporting very vulnerable people are “at breaking point and many councils are increasingly unable to turn down the chance to raise desperately needed money for social care and other local services next year. But extra council tax income will not bring in anywhere near enough money to alleviate the growing pressure on social care both now and in the future. The social care precept raises different amounts of money in different parts of the country. Social care faces a funding gap of at least £2.6bn by 2020. It cannot be left to council taxpayers alone to try and fix this crisis..”

The money councils pay does not cover the full cost of care so providers are using those who pay for their care to subsidise those financed by their local authority. This is considered unfair. There are fears care providers will focus on the south east where there is the highest proportion of self funders leaving the rest of England under resourced. BBC research established that care firms ended contracts with 95 UK Local Authorities claiming they could not provide the service for the money they received. Some firms maintain they cannot recruit or retain staff. The Local Government Association blames, "historic under-funding" and increasing numbers of old people. 69 home care companies closed during the three months to March 2017 and 25% of the UK's 2,500 home care companies could go bankrupt. Alan Long, director of a company that terminated a local authority contract said, "That was a terrible thing to do for both service users and for care staff. We absolutely did not take that lightly, but frankly what choice did we have? We just cannot do the two most basic things that you need to do in home care - pay staff the absolute minimum of a living wage and be able to recruit enough people to deliver the service." The Centre for Workforce Intelligence reckons two million or more extra carers will be needed by 2025 in England alone, for both in-home care and care homes, due to growing demand. Charities, local councils and thinktanks say the funding gap was from £1.3bn to £2bn.

It is widely believed the money given to social care in the 2017 spring budget was insufficient to solve the problems in the care system. Nigel Edwards of the Nuffield Trust thinktank, said the £1bn would cover only half the £2bn funding shortfall feared in 2017-18. He added “More and more vulnerable people are therefore going to be denied the help they need in the next year”.

Cuts to social care have been cited as a factor in an increase of 30,000 in the number of deaths during 2015. Professor Martin McKee of the London School of Hygiene & Tropical Medicine, said, "With an aging population, the NHS is ever more dependent on a well-functioning social care system. Yet social care has also faced severe cuts, with a 17% decrease in spending for older people since 2009, while the number of people aged 85 years and over has increased by 9%. To maintain current levels of social care would require an extra £1.1 billion, which the government has refused. The possibility that the cuts to health and social care are implicated in almost 30,000 excess deaths is one that needs further exploration. Given the relentless nature of the cuts, and potential link to rising mortality, we ask why is the search for a cause not being pursued with more urgency?"

People who receive social care

Large numbers of people who need social care miss out because councils have insufficient funds. Central government funding for English Local Authorities was reduced by 14% in real terms from 2011 to 2015. Residential homes for old people are closing because those who run them cannot manage on the money they receive. The effect of cuts on the health and well being of old people is impossible to quantify. The number of older people not getting care rose by 50% between 2010 and 2016. Increasing numbers get family or friends to help with care costs. Cuts to central government grants force councils to reduce the social care they pay for while simultaneously the numbers needing care increases because people are living longer and more need social care. Care is sometimes inadequate because carers are poorly trained. There has been a great deal of investment in helping people live longer but less has been done to help ensure that longer lives are worthwhile and fulfilling. Areas of social deprivation where people most need social care are least able to raise the necessary funds through council tax to pay for it.

1 in 8 of older people (1.2 million) get no help for care. 300,000 have trouble with 3 tasks or more, including dressing, washing, going to the toilet. Fewer than half those requesting care in 2015 (1.3 million) got it. 11 councils rejected over three quarters of applicants. Treatment of dementia patients was often problematic because care staff got insufficient training. Families reported patients not getting medication, staying in dirty clothes for days or going missing when homes were not secured.

The official inspection body, the Care Quality Commission, warned the sector was at "tipping point" - with the lack of care having an impact on hospitals through rising accident and emergency attendances as vulnerable people sought help.

What care people receive increasingly depends on what they can afford and on the postcode lottery (where they live) rather than on need. Insufficient investment in NHS services weakens objectives of keeping people independent and away from residential care. Local Authorities will soon have insufficient funds to carry out statutory duties.

Polly Toynbee wrote that some disabled people are issued with incontinence pads so care visits to take them to the toilet can be rationed.

People unable to wash, dress or feed themselves in some cases got no help from the council.

Analysis previously published by Age UK suggests almost 1.2 million people aged 65 and over do not receive the care and support they need with essential daily activities such as eating, dressing and bathing. That figure has shot up by 17.9% in just a year and almost by 50% since 2010, with nearly one in eight now living with some level of unmet need, it says. (Guardian report)

The government is planning changes and psychiatric patients with conditions like disabling anxiety may receive less. Mark Atkinson of disability charity, Scope said: "It is unhelpful to make crude distinctions between those with physical impairments and mental health issues because the kind of impairment someone has is not a good indicator of the costs they will face. Many disabled people will be now be anxiously waiting to hear as to whether or not these tighter rules will affect their current PIP award. The government must offer clarity and reassurance that these new measures will not negatively affect the financial support that disabled people receive now or in the future, and that they stand by their commitment to making no further changes to disability benefits in this Parliament."

The care workforce

The social care workforce broadly encompasses those who work in public services that are provided, directly or commissioned, by local councils to discharge their personal social services (PSS) responsibilities.

In England, the social care workforce comprises over one and half million people. An estimated two thirds of the workforce work for some 25,000 employers in the private and voluntary sectors. The remaining third work in the statutory sector, largely for 150 local councils with personal social services responsibilities. Data on the social care workforce is collected and analysed by Skills for Care, the national workforce organization for adult social care in England. Data is collected on the social care workforce through Skills for Care's National Minimum Data Set (NMDS-SC).

These two areas broadly break down into the responsibilities of "provision" and "assessment and commissioning" on behalf of local public finance for people felt to be in need according to eligibility criteria.

The range of work settings includes the community, hospitals, health centres, education and advice centres and people’s homes. Social care practitioners frequently work in partnership with staff from other professions, including health, housing, education, advice and advocacy services and the law.

Providers are under pressure, find it hard to keep staff, preserve quality of care and stay in business. Local authorities are forced to make cuts, discharging patients from hospital is delayed due to lack of support in the community.

Young carers

Some carer are still children who help look after a sick or disabled relative. Their needs are often overlooked and councils do not have the resources to support very young carers.

Qualifications

The Care Standards Act 2000, as well as establishing regulations covering service provision, brought greater recognition for the profession of social work with the introduction of a social work degree and social workers’ register. To become a social worker in the UK and use the title, students need to complete an Honours degree or postgraduate MA in Social Work. There are access courses for mature students, trainee schemes and employment based routes to gaining the qualification. Qualified social workers are currently required to register with the Health and Care Professions Council (HCPC) before commencing practice. Social workers are also required to ensure that they keep their training and knowledge up-to-date with current developments in the field.

Occupational Therapy is another important profession working in health and social care settings, contributing to the promotion of people's independence through advice and provision of equipment, and enhancing the suitability of housing through Adaptations.

There are many other social care roles for which other qualifications, experience and training may be necessary.

Examples of the range of professions within this field include policy makers, researchers, academics, project workers, support workers, employed care staff (in residential or domiciliary care settings sometimes confusingly referred to as "carers") and personal assistants.

Social care organisations

UK Social workers are currently registered with the Health Professions Council which sets codes of conduct and practice. Through the work of the Munro Review, the Social Work Reform Board and the piloting of social work practices, Government aims to give greater autonomy to social workers. The Reform Board recommended the development of a professional college. The College of Social Work has been set up with the aim of improving and supporting social work by leading the development of the profession and representing it in discussions with organisations that regulate, train, work with, and are affected by social work. Social care services are regulated by the Care Quality Commission.

Other social care organisations include the Social Care Institute for Excellence - an independent charity that identifies and transfers knowledge about good practice, and Skills for Care, the national lead agency for policy and strategy related to workforce development and the adult social care workforce.

The National Skills Academy for Social Care, launched in 2009, provides learning support and training practice for social care workers and employers in England with a specific remit on leadership development.

The Association of Directors of Adult Social Services is the official voice of senior social care managers in England.

There are many other voluntary and independent organisations that exist to support the delivery of social care. These exist to support both the social care workforce and people who use services, and include user-led organisations.

Future directions

Local authority spending on adult social care is a demand on the local tax revenue and for this reason and associated costs to the NHS from hospital admissions, Social care is high on the UK government’s agenda, with an aim of integration of health, social care and education to reflect the overlap between these areas.

The Coalition Government's plans for adult social care services are set out in 'A vision for adult social care: capable communities and active citizens', which was published in November 2010. The aim is to make services more personalised, more preventative and more focused on delivering the best outcomes for the people who use them. The Government wants people eligible for services to be advised of the public money to be allocated to their needs (their "Personal care budget") and to encourage care and support to be accessed from a partnership between individuals, communities, the voluntary sector, the NHS and councils. The rollout of personal budgets will be extended, and councils and NHS organisations will be expected to work together in an integrated way to commission services. The Health and Social Care Bill published in January 2011 outlines these changes in more detail.

A 10-year strategy for mental health, New Horizons was published in December 2009 by the Labour government. The current government is due to publish a new mental health strategy for England.

Dementia care is an area that has received increasing attention, following the launch of the National Dementia Strategy in February 2009. This strategy focuses on ‘living well’ with dementia and aims to provide those living with dementia and their carers information and support that maintains dignity and increases choice. With rises in life expectancy leading to increase in people affected by dementia, The Coalition Government has indicated that dementia remains a priority. Age UK estimated in 2014 that 900,000 people in England between the age of 65 and 89 had unmet social care needs, and said in 2015 that the figure was increasing because 40% cuts to government funding for local councils, which provide the bulk of social care, had had a devastating impact.

In children’s services, Government will focus on helping the poorest and most vulnerable families, through targeted and early intervention. Ministers across Government have made a commitment to end child poverty by 2020. The establishment of the Centre for Excellence and Outcomes in Children’s and Young People’s Services is intended to support this agenda in England.

Developing the skills of the social care workforce is a continuous priority, specifically in response to changes in the social care sector and media coverage of social care issues. Following the recommendations of the Social Work Taskforce (2009), The College of Social Work has been set up. The College will represent and support social workers and help maintain standards for the profession. Skills for Care is the lead national body for strategy and policy in relation to workforce development and the social care workforce.

Robots are being developed which it is hoped will be able to help with some social care.