Social care 360: quality

This content relates to the following topics:

12. Care quality is rising. Probably.

More services are rated good or outstanding, though we may need to be cautious about the apparent improvement

In its 2018 State of Care report, the Care Quality Commission (CQC) says the overall quality of social care has improved slightly. Its data shows a higher percentage of services rated good or outstanding for each of the past three years.

This sounds good news – and may well be – but there are several reasons to be cautious about this apparent increase. The CQC's new inspection regime, introduced in late 2014 and generally regarded as tougher than its predecessor, brought forward inspections of services about which there were concerns. So it would not be surprising to find more homes requiring improvement in the first years of inspections and for more better-quality services to be inspected as the years progress.

Once a service is rated good, it is inspected less frequently so its rating is held for longer, which again tends to push up reported standards. Services that have been rated as inadequate or requiring improvement are also more likely to close.

In 2016/17, the CQC said that factors associated with good services included the presence of a registered manager in care homes. Size was also a factor, with smaller care homes (1–10 beds) rated better than larger ones (more than 49 beds). This may be because many smaller homes are for people with learning disabilities and these homes tend to perform better overall, as in domiciliary care, where services catering to smaller numbers of people were also performing better.

It is worth noting that inspections inevitably provide a measure based on a 'snapshot' of a service's performance, which may not necessarily be an accurate measure over a longer period.

There is also significant local variation in care quality but no clear answers as to why it exists. Local service make-up may be one factor: of the different types of adult social care, nursing homes tend to be lowest rated, so an area with a lower proportion of nursing homes may appear to have a higher overall quality of care. Some local authorities provide more support to struggling homes than others and this may also be a factor.


13. Service users say they're satisfied

Satisfaction with publicly-funded care has remained at high levels

Service users' satisfaction with the care funded by local authorities appears to have remained consistently high over the past four years, with approximately 65 per cent saying they are either extremely or very satisfied. Fewer than 5 per cent say they are dissatisfied.

In some ways this is a surprising figure, appearing to contradict anecdotal concerns that financial constraints have affected the volume and quality of the packages of care provided. There is little in the satisfaction data to suggest this, though there has been a small, statistically significant, increase in dissatisfaction between 2016/17 and 2017/18.

One interpretation of this data is therefore that, despite declining budgets, local authorities have managed to protect the services they provide to – an admittedly declining number of – individuals who are eligible for services.

However, the results do contrast with the bi-annual survey of adult carers, which asks about satisfaction not only with services for carers themselves but also with services provided to the person they care for. Here, in 2016/17 only 39 per cent said they were extremely or very satisfied, and this number may have declined since the first survey in 2012/13, although changes to methodology make this hard to determine.

Another reason for caution is Local Government Ombudsman (LGO) data showing a rising number of complaints about adult social care. The LGO notes this may indicate greater awareness of the LGO and/or greater willingness to complain but also highlights concern that increasingly the complaints they see relate to 'systemic issues' rather than one-off mistakes.

Some evidence also suggests that a positive satisfaction rating may conceal variations in experience of social care.

It is also important to note that, despite the high level of overall satisfaction, there is some variation between different groups responding to the survey. People over 65 report lower levels of satisfaction than those aged 18–64. Black and minority ethnic people also report lower levels of satisfaction than white respondents. People in residential care are more likely to be satisfied than those receiving nursing or community care services.

There is no data available about the satisfaction of people who fund their own care services (including any who no longer receive publicly-funded care). However, we do have data about wider public satisfaction with social care, which is covered in the next indicator.

14. Public satisfaction is low

Satisfaction with social care is lower than for the NHS but this may reflect less experience and understanding of it

Questions asked: 'All in all, how satisfied or dissatisfied would you say you are with the way in which the National Health Service runs nowadays?' (in 2018 n=782 for 65+, n=1748 for 18–64) and 'How satisfied or dissatisfied are you with social care provided by local authorities for people who cannot look after themselves because of illness, disability or old age?' (in 2018 n=274 for 65+, n=570 for 18–64). The King's Fund analysis of NatCen Social Research's BSA survey data.

Public satisfaction with state-provided social care has remained stable at 25 per cent, compared to public satisfaction with the NHS of over 50 per cent. This level of satisfaction also contrasts, of course, with much higher levels of satisfaction expressed by people who are actually using publicly funded services (see indicator 13). And, interestingly, whereas among actual users of services, older people are less satisfied with their care, among the public generally, older people are more likely to express satisfaction. 

However, there are several reasons to be cautious about this measure of public satisfaction.

Unlike for the NHS, most people do not have direct experience of using adult social care services (though some will have direct experience of arranging care for someone else). Indeed, many may not understand what the term 'social care' means and may not understand clearly the distinction between services provided by the NHS and those provided as social care.

Probably as a consequence, much higher levels of people sit on the fence: 31 per cent say they are neither satisfied nor dissatisfied and 10 per cent say they 'don't know'. This compares to the NHS, about which most people express a view, with 16 per cent saying they are 'neither satisfied nor dissatisfied' and hardly anyone (0.4 per cent) saying they 'don’t know'.

Another reason might be that some who express an opinion on social care may be basing it on what they hear in the news. Analysis of national media coverage for social care between June 2017 and April 2018 found the word 'crisis' was often used and that social care was predominantly framed in the press as an 'intractable problem that results from a combination of decreasing financial resources (mainly due to government policies) and increasing demands (due to a rising number of older people in need of support)'.

The indicator may therefore be mapping a public concern about social care and lack of understanding of it rather than – or as well as – public dissatisfaction.


15. Direct payments remain at a low level

The number of service users receiving direct payments has stalled, with a far higher percentage of working-age adults using them than older people

Direct payments should be a valuable indicator of 'personalisation' of services – the amount of control an individual has over their care and support. 

Since 2015, everyone receiving support in the community from their local authority must receive a personal budget setting out the money allocated to meet their needs. People can choose how to receive their personal budget and one option is a direct payment – actual cash for the person to organise and pay for their care and support themselves (often by directly hiring people to work for them as personal assistants who will carry out a wide range of support in the home, at leisure or in work).

Yet the number of people receiving direct payments, after growing for several years, has now stalled. The proportion increased by just 0.2 per cent in 2017/18 and, since the total number of service users fell, 128,000 people were receiving direct payments at the end of the year, down from 130,000 the previous year. 

We do not fully understand the reasons for this trend, but does it mean that personalisation is also stalling? Certainly older people in particular appear reluctant to take advantage of the options that direct payments offer: just 17.5 per cent of over-65s take direct payments compared to over 40 per cent of working-age adults.

However, the levelling-off may not be due simply to lack of interest. Support groups say that a key factor is support for take-up. People often need help to manage services, particularly if they opt to directly employ personal assistants, and this support has not grown in the way envisaged by the 2014 Care Act.

Availability of personal assistants and services to choose from may also be a factor: if local services are limited to one or two options, users may conclude they may as well receive them direct from the local authority rather than go to the extra effort of managing them themselves.

These factors may help to explain the wide variation between local authorities in the amount of take-up: in some local authorities fewer than 9 per cent of people opt for a direct payment yet in others it is nearly 60 per cent.


16. Fewer people are entering care homes

Overall there has been a decline in people going into residential and nursing care homes – but a surprising increase for working-age adults

Avoiding permanent placements in residential care is seen as an indicator of the quality of the social care system, partly because it is a measure of delayed dependency and also because people prefer to remain independent at home for as long as possible. Residential care is also typically more expensive than home-based care (though this depends on the care provided at home – some high-intensity home-based packages can be very expensive).

It is therefore encouraging that the overall number of people entering residential or nursing care homes has – as the chart above demonstrates – declined over the past few years. For older people, the rate has fallen from 659 per 100,000 people in 2014/15 to 586 per 100,000 in 2017/18. For working-age adults, the fall has been marginal, from 14.1 per 100,000 in 2014/15 to 14.0 in 2017/18.

However, there are notes of caution. One comes from 'serious concerns' expressed by directors of adult social services in their autumn 2018 survey that overall numbers admitted to residential care may be set to increase again, partly as a result of the 'unintended consequences' of efforts to reduce the number of delayed transfers of care from hospital.

A second note of caution comes from an increase in the number of working-age adults entering homes in 2017/18 after three years of decline.

The increase is small and, because relatively few working-age adults enter residential care, amounts to only around 400 more people across 152 local authorities. It may therefore be a one-off anomaly. If not, an optimistic hypothesis would be that more working-age people are leaving NHS hospitals and entering residential due to the 'homes not hospitals' principles of the Transforming Care agenda for people with learning disabilities and autism. A less optimistic one would be that commissioners are considering residential care for some people with very high support needs because of the high costs of providing care at home.

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