When the Care Act received Royal Assent in 2014, we were already over three years into a government hell bent on austerity. This included stringent cuts to councils and these were starting to filter through to adult social care. With this in mind, a new approach to care, which focussed on assets rather than deficits, that talked about prevention rather than intervention, and was centred around wellbeing rather than sickness made both political and economic sense.
From a provider perspective, the Care Act embedded the person-centred approach to care that organisations were seeking to implement and made clear a framework for assessment that recognised different levels of need and encouraged prevention within that structure. However, even ten years ago, it was recognised that the costs of care should be capped, and that the state should play a greater part in making care affordable for all.
Fast forward ten years and the situation has got substantially more bleak for every aspect of the care sector. Providers have faced many more years of austerity, with fee rates for publicly funded care being squeezed across the country. Patterns of commissioning have changed too, with a significant move away from the security of block contracts to a stress full spot purchasing arrangement, and the cross subsidy that now exists between publicly funded care and people who have to fund their own care has caused an ever more fragmented market to appear.
The central tenets around prevention and wellbeing are also under attack.
Further squeezes on public services have meant that other local infrastructure services and those provided by the voluntary and community sector have reduced, making it harder for people to access support ‘up stream’, meaning opportunities for early intervention are missed, minimising some of the ambitions of the Act to support greater independence, choice and control."
The Care Act came into being in the face of a mixed market, with the collapse of Southern Cross homes, which at its peak operated 750 homes, coming right at the beginning of the new parliament. The legislation that followed this seismic shock unsurprisingly had a greater focus on market oversight – and indeed the responsibilities within the Act for authorities to manage the market. However, the concept of an effective market is built on the belief that market forces will deliver efficiency, quality and innovation, as well as providing capable and empowered consumers with greater choice.
It also relies on a balance of purchasing power, enabling consumers to choose the price point to suit them for the service they need/ want/ can afford. This can work for the well informed, rational consumer, who is not making the purchase in a crisis and who has sufficient funds to buy their own care, but since 60-70 per cent of care purchased is paid for by the public pound, often in crisis, it is not how it works out in reality.
Of course, things have not stood still in terms of models of delivery, and the last ten years have also seen a further shift away from residential care, continuing a trend that started with the Community Care Act. Recent years have seen health and council commissioners talk more strongly about housing-based options – including greater focus on home care and growth of specialist housing for older people. In addition, providers have developed their own specialisms including the way they support people with dementia and the way in which they have utilised technology to support greater independence.
However, it would be a struggle to suggest that providers have been funded to adhere to the fidelity of any of these newer models, or indeed the augmentation of existing models. It is telling that more visionary approaches, such as the introduction of ‘self managing teams’ in homecare delivery (Buurtzorg), household approaches to residential care, shared lives and homeshare and even government backed approaches to the implementation of personal budgets have not universally gathered pace. Operational constraints driven through restrictions in available funds mean these changes are often viewed through the lens of pilots or innovations rather than ongoing approaches to tackle communities with changing needs, and generally investment in transformation is led and sustained by providers.
It is really important that the Care Act can deliver on its ambitions for fairness and choice for people – perhaps it is time to resurrect the ambitions of the Care Act into a National Care Covenant. To use the language of the Archbishops’ Commission on Reimagining Care, we need a ‘social covenant’ that sets out the role and contribution of people, communities and government and clear expectations of what support should be available. This support needs to be universally accessible, rather than rationed due to the postcode lottery of funding and resources.
Market shaping did not have the workforce in scope, an oversight allowing the lack of strategic focus on the social care workforce to roll forward a further ten years. Action is needed to improve the pay, terms and conditions of care workers, help us all celebrate and recognise their value and ensure we have the size of workforce we will need to deliver consistent, high-quality care and support to the increasing numbers of people who need it (and their families) now and in the future. Current and future governments must work with us to achieve this.
Aside from austerity, the Care Act has also had to steer its way through the first global pandemic for over 100 years. No mean feat for any piece of legislation, and it was notable that one of the earliest responses to the pandemic was to allow councils to downgrade the statutory duty held with the act through a process of announcing ‘easements’, largely resulting in an approach to care that was driven through the lens of ‘life and limb’. Thankfully, there was limited use of this approach, however, the pandemic did demonstrate that the breadth of responsibility within the Act required councils to have a much greater engagement with the ever-growing body of self-funders, who very firmly had to be brought in the purview of the upper tier authority.
One of the positive legacies of the pandemic has been the much sharper focus on real time data about social care. Whilst we can debate the process and the approach to data gathering, there can be no doubt that understanding what is happening on the ground, to people in communities, can only be of value to the wider understanding of care."
The latest data on local government finance shows just how far spending on care has moved in the last ten years, with it now taking up on average 65 per cent of all government finances. This means that discharging this legislation in an effective way is, in essence, local government’s primary purpose. That should be a stark reminder for both local and national politicians when reflecting the importance of care to their constituencies, and most importantly to their constituents, and encourage them to be bold and speak up for care.
