The UK government promised the public a green paper on social care. Its goal is to address urgent concerns about funding, which many see as failing and unfair. The government acknowledges the problems—Boris Johnson’s first speech as prime minister promised to “fix the crisis in social care once and for all.” The ongoing COVID-19 pandemic has highlighted, via a very intense spotlight, the long-running, unsolved issues within social care. Without these essential changes to social care, the NHS long-term plan may fall short of its intent to improve patient care and health outcomes.
Simon Stevens (NHS England CEO) recently added his personal voice to the growing ‘call to arms’ of social care reform happening within the next 12 months – a plea I strongly echo and for the reasons detailed below one I hope you join me in amplifying.
Separate (but closely related) systems
A wide range of individuals and institutions have the misconception that General Practice (GP) surgeries, hospitals, and social care operate under the same system within the NHS. It’s an understandable mistake—in terms of policy and planning, a fundamental alignment of health needs makes sense. Instead, there are two distinct systems: the NHS is responsible for allocating funds and running primary and secondary care in the UK, while social care is organized through social services and funded and run by local authorities. One of the most pressing concerns, intensified by the COVID-19 crisis, is adult social care, which includes support for older people and those living with a disability or mental or physical illness.
The NHS is free at the point of delivery to patients and drawn from general taxation, but social care is not. Social care is means-tested and free only to those who have assets below £23,250. Many believe that until the disparities between the NHS and social care are ironed out—and particularly with respect to funding—neither system will run efficiently, cost-effectively, or fairly. The two systems are so closely related that problems in one creates serious implications for the other.
Preserving hospital beds only for those who truly need inpatient care
In this article and others in our series on health, I suggest a pragmatic approach to reviewing the structure of the NHS, where only those who truly need inpatient care end up in a hospital bed. The NHS long-term plan is broadly in line with this practical approach and the need to change healthcare delivery if it is to serve modern-day health demands. Yet, for this to work effectively, the NHS system and practices need to align with those for social care. At the moment, this connection is struggling and requires a fundamental review.
Social care is possibly a bigger headache for the NHS than adapting primary care to post-COVID needs. Since 2009, the government has squeezed local authority funding. Budget cuts have caused 900,000 people to lose eligibility over the past five years. Worse yet, the need for support is outpacing social care funding. The NHS will better succeed in expanding provisions for care in communities if social care is reformed rapidly and in line with the NHS long-term plan.
A stark mismatch routinely occurs between the NHS and social care when it comes to hospital discharge. In June 2016, delayed discharges caused a loss of over 155,000 bed days, almost 80% more than the same period five years earlier and the most significant loss to date.
The NHS system of discharge runs into friction with the social care provision for support in the community. Often, hospital beds are still occupied by people who have been treated successfully but are waiting for transfer to social care. Many patients need a carer or specialist equipment to return home.
Older patients may have problems with failing physical or mental health and require a different setting, such as a residential home or a community hospital. Frail, older patients who have long-term illnesses might need their symptoms managed rather than immediate medical attention. So, preventative outpatient care is necessary.
The four major issues that must change in adult social care
To address some of the fundamental problems in social care, any proposed overhaul must address the following:
1. A lack of social care provision
The lack of provision in social care is one of the main factors in delaying the discharge of patients from hospitals. Social care providers often struggle to generate a profit margin due to the pressure on their income. To partially offset the lack of local authority funding, self-payers pay a disproportionately high amount for their care provision. Eligibility criteria are not uniform throughout the UK, and this contributes to the perception that social care is inherently unfair. Those with considerable care and support needs (estimated to be 10% of those over 65 years, according to the Dilnot Commission) sometimes pay vast sums (e.g., over £100,000) for their care, requiring many to sell their home.
Particular challenges include:
- A high number of vacancies exist within the care sector; wages are meager. Pay must be sufficiently high to attract staff.
- Care workers have limited time to spend with clients, sometimes as little as 15 minutes per visit.
- A high turnover of staff and a significant number of vacancies result in the use of agency staff, costing providers more than permanent staff and disrupting the continuity of care.
For a longer-term approach to change, NHS nursing and social care could benefit from unification under the same standards and similar rates of pay. It may even be possible to house both systems under a single organization—particularly as the same government department currently oversees both. At the very least, a ‘nationalization’ of social care could remove the profit margin element for care providers—making more resources available to spend on services for the community.
2. A reactive approach to social care
The whole social care system is designed as a reactive model, which only responds once a person’s needs become critical. Looking at early intervention and finding ways to prevent the need for hospitalization minimizes the risk of people ending up in hospital when their long-term condition could be better managed within the community. At the moment, the elderly and less able patients can end up in hospitals because community-based options are not available.
A more proactive approach could identify at-risk groups, particularly by applying population health techniques. If we identify those at risk early, the system could prevent the need for a more resource-intensive service following a marked decline in health or a severe injury.
Greater NHS and local authority collaboration could help to turn a reactive and potentially expensive intervention into more proactive, cheaper, and appropriate care. Lengthy post-treatment hospital stays for elderly patients can disorient individuals and make them less able to return home. Plus, someone who is seriously ill and needs life-saving inpatient care requires access to the hospital beds currently filled by elderly patients.
There are examples of multidisciplinary teams from NHS and social care collaborating to deliver better health outcomes. These groups may avoid the need for hospital admission or work together to return a patient to their home promptly. Strategic Transformation Partnerships (STPs) and Integrated Care Systems (ICS) are promoting best practice models for this kind of collaboration. But, until a single organization within each geographical area provides both health and social care, the true benefits of providing integrated care may remain elusive.
3. Avoiding changes to traditional, outmoded, or ineffectual practices
Internal politics and institutional customs can prevent partnerships from finding innovative ways to solve problems. Reviewing existing structures and practices can identify efficiencies and improve methods of delivering patient-centered care. An example is to extend the collaboration between the NHS and social care teams by using trained “navigators.”
The complexity of the social care system and NHS procedures are complicated for patients and their relatives to navigate. Assigned navigators can help steer and support families through the NHS and social care system. This approach minimizes delays and costs by accelerating decision-making and surfacing available options. Navigators benefit both practices and communities by supporting at-risk groups. This approach frees up doctors, nurses, clinicians, and other providers to focus on the highly-skilled tasks that they alone can perform.
4. Avoiding pragmatic approaches to funding
There are many ways to transform social care and the NHS for the better without additional funding. However, years of underfunding social care must change to provide appropriate care options. The Local Government Association estimates that social care currently faces a funding gap of £4.3 billion.
The Nuffield Trust, in a blog from 2019, outlined some of the potential ways to fund social care. It suggests that a workable approach to providing funding has four core principles:
- Does it raise money for now and in the future?
- Does it pool financial risk?
- Is it fair?
- Is it understandable and transparent?
The Nuffield Trust suggests that a combination of approaches could meet these four principles and points out that:
- Social care funding does not provide funding for the future. It aims to cover costs through a mix of local authority and personal contributions that are dependent on income and assets.
- Future funding needs to consider growing demand without relying solely on working-age adults for payments.
- More individual responsibility and less state intervention mean that any funding scheme needs a careful balance of taxation and extended national insurance contributions.
- Pooling the financial risk provides security for the whole population because it ensures equitable access to care.
- Everyone needs to pay what they can afford to create a fair system. The government must collect funds nationally to minimize local disparities.
Why the government must accept the challenge to change
I am in favor of the funding vision described above—and of drawing upon the experiences of other countries with similar issues. Germany and Japan both have mandatory insurance schemes. If we adopt a comparable scheme, together with taxation and transparency, I think the country will be well on the way to ‘fixing’ social care. This could unite social care and the health service systems under a single organization. It would no longer be dysfunctional and would fully complement the health service—facilitating holistic changes to resource use that benefit everyone.
We have a once-in-a-generation opportunity to introduce such fundamental changes. If the government doesn’t rise to the occasion now, while the COVID-19 crisis has intensified the need for quality care, the problem will persist, expand—and become far worse over time.