12. Care quality ratings have increased slightly
More services are now rated ‘good’ or ‘outstanding’ but 1 in 6 are still below standard
Over the past four years, the percentage of adult social care services rated ‘good’ or ‘outstanding’ by the Care Quality Commission (CQC) has continued to edge upwards. By April 2019, 3.5 per cent of services were rated ‘outstanding’ and a further 80 per cent were rated ‘good’, up slightly on April 2018.
This suggests there are some excellent care services in England to be celebrated (and learnt from: an Outstanding Society, comprised of care homes rated outstanding by the CQC, exists to share their experience and help to drive up quality across the sector). Similarly, people using care services report high levels of satisfaction (see indicator 13).
Why, then, are public perceptions of care services (see indicator 14) not as positive as might be expected?
One factor is that there are still 1 in 6 services – more than 3,700 care homes and home care services – that are below par. They are not evenly distributed across England, so in some parts of the country the ratio of poor performers is actually much higher.
Another factor is likely to be media coverage. There have been several high-profile reports of the very worst care, including abuse, which understandably stick in people’s minds.
And not every person using even a highly rated service will necessarily have a good or outstanding experience (though, of course, it is equally true that some people in lower-rated services will have a good experience).
13. Satisfaction among people using services remains high
Two-thirds of people receiving publicly funded services say they are ‘very’ or ‘extremely’ satisfied
Since 2014/15, the annual survey of people using local authority social care has consistently found that around two-thirds of people are satisfied with the services they receive.
The simplest, most positive explanation of these results is that the quality of services received has held up well. This high level of satisfaction is consistent with CQC ratings of care services (see indicator 12). Certainly, councils do receive compliments about the services they provide, as well as complaints, though they do not necessarily record or report positive feedback.
However, there are reasons to be cautious about these findings. First, there is research evidence to suggest that a positive satisfaction rating of social care may conceal variations in the experience of people using services. Some people, for example, may be expressing gratitude for a service received rather than satisfaction. Others may even fear withdrawal of services if they express dissatisfaction.
There is also alternative evidence from carers. A biennial survey of satisfaction with services received from social services – for carers themselves but also services for the people they care for – finds only 39 per cent satisfaction with services. One explanation for this is that, in the face of the decline in publicly funded care, carers are having to do more.
There are also other systemic indicators of problems with satisfaction. The Local Government and Social Care Ombudsman found in its 2018/19 report that the number of complaints was static but they were ‘ever more serious’. More complaints were being upheld, with two-thirds of investigations finding faults – ‘many of which appear to be driven by attempts to ration scarce resources’.
Finally, the Office for National Statistics uses a measure of user-rated quality in its annual survey of adult social care productivity. This includes but goes beyond the satisfaction data from service users1 headlined in this indicator. Between 2016/17 and 2018/19, it found that quality had in fact declined, notably in community support for people with learning disabilities.
Satisfaction also varies between service users and according to setting. Working-age adults are significantly more satisfied with their care (68 per cent) than older adults (62 per cent); white service users report higher satisfaction than black and minority ethnic service users; people using residential care report higher satisfaction than nursing care or community care service users; and service users and carers in London report lower satisfaction than service users in other areas of the country.
- 1. Think Local, Act Personal notes that ‘not everyone likes the term “service user” and may prefer to be described simply as a 'person who uses services'. We use the term ‘service user’ occasionally in this report for brevity.
14. Public satisfaction remains low
The public is less satisfied with social care than the NHS but has less experience of it
Public satisfaction with social care services in England, measured by the British Social Attitudes (BSA) survey, was 29 per cent in 2019, a figure that has remained broadly unchanged since 2012. The level of satisfaction with social care has also been consistently lower than that for the NHS since 2012. Unlike the NHS, in 2019 there was no difference in satisfaction with social care between age groups.
Satisfaction with social care is also lower than that for individual NHS services. For example, public satisfaction with GP services was 68 per cent, 60 per cent for dentistry, 71 per cent for outpatient services, 64 per cent for inpatients, and 54 per cent for accident and emergency (A&E) services.
For the first time, the 2019 BSA survey measured whether there are differences in satisfaction between users and non-users of social care. It finds that 14 per cent of respondents said they had used or been in contact with adult social care services in the previous 12 months, with a fairly even split between those who were satisfied (38 per cent) and those who were not (47 per cent).
However, it is important to bear in mind that previous work has shown that many people may not understand what the term 'social care' means, or may not understand the distinction between services provided by the NHS and those provided as social care.
We also have to be cautious because, as with some health areas such as ‘inpatients’, social care is a very broad area. Services in the community for younger adults with a learning disability are very different to those provided for much older people with dementia in care homes, for example. Yet we only have this one measure to describe them all. Additionally, we have no way of knowing whether satisfaction or dissatisfaction relates to eligibility for publicly funded care (since social care is means tested), quality of services (see indicator 12) or availability of services locally.
15. Usage of direct payments may have peaked
The proportion of service users receiving direct payments fell again in 2018/19
Direct payments – cash paid to an individual to allow them to purchase their own care – should in theory allow people greater choice over the services they receive. Yet the numbers taking up direct payments have been falling since 2016/17 and the proportion has levelled off at around 28 per cent. Working-age adults are far more likely to use direct payments than older people – 39.9 per cent and 17.6 per cent respectively.
- What is a direct payment?
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. One option is a direct payment – money paid to the person to organise and pay for their own care and support themselves (often by hiring someone to work for them as a personal assistant who carries out a wide range of support tasks for them in the home, at leisure or in work).
There is likely to be more than one reason why direct payments appear to be falling after having peaked. Opting for direct payment requires more involvement and responsibility than simply receiving a service, and people need support to manage one. However, service user groups say some local authorities offer far more support than others. This may reflect different approaches to personal budgets by local authorities or even individual social workers within those authorities.
Similarly, if there is little choice of local services on which to spend a direct payment, people may wonder whether it is worth the extra work. If an individual wants to employ their own carer (personal assistant), then direct payments certainly make that possible. If they do not, then direct payments may be less appealing. Just under half (47 per cent) of people receiving a direct payment for their care and support needs were estimated to be employing staff in 2018.
16. The fall in care home admissions has slowed
More older people entered care homes in 2018/19 but the overall trend remains downward
The continuing fall in the number of permanent placements by councils in residential or nursing homes is seen as a quality marker because it suggests that more people are living independently at home, where they prefer to be.
Yet this trend has slowed almost to a standstill, and there are some underlying issues.
- For older people, the rate of decline has slowed significantly from a 5 per cent fall per 100,000 population between 2014/15 and 2015/16 to a 1 per cent fall between 2017/18 and 2018/19. With a larger population, the actual number of admissions in 2018/19 has, in fact, increased.
- Care home placements now make up a slightly larger percentage of social care services being provided by local authorities.
- The proportion of working-age adults going into a home dropped slightly in 2018/19 but it remains above the 2015/16 level.
Why has the rate slowed so much? One explanation would be that most of the improvement has already been made – in effect, the proportion of the population that could be supported to remain at home is already getting that support and only those who really need residential care are taking it up.
However, there are several other possible explanations that are less positive. One is the cost of care. For people (often working-age adults) who require very intensive support, home-based packages may be more expensive than a care home. Councils – who are entitled to take cost of care into account when deciding on care packages (though they cannot set arbitrary upper limits on cost) – may in practice be funding more of these high-cost individuals in care homes.
Another explanation could be pressure to reduce delayed transfers of care from hospital. In 2018, directors of adult social services expressly warned that the total number of people admitted to care homes might increase because of the need at the time to free up hospital beds as quickly as possible (see indicator 17). Four in five directors of adult social care said there had been an increase in rapid discharges to short-term care home placements that then became long term.
One other possible explanation is service reductions. Councils are focusing their long-term support on people with the greatest needs. A higher proportion of these people are likely to need a care home, which would explain why the proportion of service users going into care homes has increased.
A note of caution on this indicator though: it does not include data on people who fully fund their own care home place and do not rely on the local authority to manage the placement. Since these decisions to enter a home are made by individuals and their families without any financial support – and, quite possibly, without advice – from local authorities, the trend could be different.