Social care for older people: Home truths

Good morning everyone. I am very pleased to present the findings of the report on behalf of the project team. That is Ruth Thorlby and Holly Holder from the Nuffield Trust, and Patrick Hall and Anna Charles from The King’s Fund.  And if you have got any really difficult questions, I am sure they would be delighted to answer them.  Thank you.  So this is what we are going to cover very quickly.  The project was really about looking at what has happened to social care for older people over the last five years.  And although some of the messages will not be that unfamiliar, I think what is different, and what is distinctive about the report that we are publishing today, is that we are looking at it from the perspectives of the local authorities, of care providers, and the NHS, and most importantly of all what this means for older people and their families and carers.  So we are taking a 360 degree view.  We have no particular axe to grind about any of those perspectives as two independent think tanks.

And what we did essentially, we looked at a load of data and numbers, and evidence. We talked to a lot of people in four very different parts of the country, from a range of services and backgrounds, and last but not least we were delighted to be commissioned by the Richmond Group of Charities to talk to a small group of older people and their carers about their experience. And in some ways this is the most powerful testimony you might be hearing today.  Because behind all of the statistics in our report there are people’s lives and their stories, and they are brought out very powerfully I think in the report that Richmond Group are publishing today alongside our report, and you will be hearing more from Tom Wright shortly.

So what did we find? First of all big reductions in council spending, even if you adjust it for the aging population. 81% of councils have cut spending, gross spending, over the last five years, and most of them by at least 10%.  There are some exceptions.  18 councils have managed to maintain or even increase spending, but as you can see the overall picture is one of reductions in spend.  And bearing in mind, over this period, this five/six year period, the number of over 85s, these are the people that are going to make the biggest demands on health and social care, have increased by around 11%.  So try and keep that figure in your mind as we work through the findings.

And it is not just social care. And you will see, you can’t see this terribly well, but there are fewer GPs per head of the older population over the last few years, and district nurses. There are 14% fewer district nurses than there were two years ago, 28% since 2009.  So there is a pattern here of underinvestment across a range of services that keep people at home.  So despite all the rhetoric about care closer to home, keeping people out of hospital, the key metrics about money, and workforce are moving entirely in the wrong direction.  And a lot of these points about providers, people that provide social care services, will be familiar.  But what emerges from this is an increasing polarisation of the market, that if you live in an affluent area the care market is actually in many places very buoyant indeed, because there are a lot of people who are paying for their own care, self funders.  And we also see in many places, the market is being propped up by those self funders, who in some cases are paying up to 40% more than the local authority rate.  So there is a lot of cross subsidy going on.

And we worry most about providers in areas where they are very reliant on local authority contracts, they don’t have many self funders. And our prediction is that it is a matter of when but not if we see further provider failures. Our biggest concern is about the state of the home care provider market.  And let me just show you one graph that picks it up.  This is why people get stuck in hospital, going back to 2010.  And if you look at that thick orange line, that is the number of people stuck in hospital because they are waiting for packages of care at home, a 40% increase in the last year alone, 160% increase over the last five years.  So the writing is on the wall.  And this is an astronomical rise, nearly 36,000 delayed days.  This is now the biggest single cause of people getting stuck in hospital, so it really is very, very worrying.

Most importantly of all, what did we say about the impact of all of this on older people and their carers? We found that councils have worked very, very hard, to use austerity to focus on making better use of resources and services like reablement, in many cases have successfully reduced the need for long term care. And councils generally have sought to protect those with the highest needs.  But they are running out of road to make further savings.  And despite the aging population, that 11% increase, and not just the numbers, but the fact that older people now have more complex and more acute needs, it is really quite astonishing, and I use the word demography defined, that 26% fewer, at least 26% fewer old people, are getting publicly funded care.  And even more alarming is that nobody has a clear picture of what has happened to them, and the actual extent of unmet need.  It may be paradoxical then that satisfaction levels of people using social care has remained relatively buoyant, that underlines our concern about what is happening to people that fall outside of the system.

But it is also significant that satisfaction levels of carers are much lower, and they are falling. And there is evidence that actually carers are doing much more of the heavy lifting than they used to. We also see that complaints to the local government ombudsman are rising, and that is ominous, because more of them are being upheld.  And that suggests to us that councils are finding it very, very hard, much harder to meet their legal requirements.  And I suppose putting that together our headline conclusion is that access to care depends increasingly on what people can afford, and where they live.

So where does that leave us? The funding outlook is bleak, and we don’t want to get too absorbed in the detail of this change. But if we look at the right hand side of the graph, and if we look at those purple bars, those are based on the government’s own estimates of what is going to happen to social care spending.  And you can see even by their estimates it is going to continue to fall for the next year at least.  And it won’t be until the new better care fund money comes in in 2018 and 2019 that things begin to change.  But we see even the most optimistic assumption, we see an increase of just 0.6 of 1% average over the lifetime of the parliament against probably a need of around a 4% real terms increase just to stand still.  And we talk in the report about the limited impact of the precept, and to what extent councils can use that, not just this year as most have done, but every year for the next four years.  And then we have got the uncertainties of Brexit, the impact on the workforce, the impact on public finances.  And as Chris Hobson of NHS Providers said on the Marr show on Sunday, ‘Something has got to give’.  And that applies to social care as well as the NHS.

So where do we go from here? We kind of set out three potential and strategic challenges that need to be addressed, and these are not mutually exclusive. And the first is to ask the question well can councils continue to achieve more with less?  Can they deliver further savings?  Possibly, but we do not think that will close the funding gap in any shape or form.  So we are saying very clearly that the extra money the government has promised, the £1.5 billion in 2019, that is too little too late, at the minimum that should be brought forward to address some of the immediate pressures.  We are also saying that we need to accelerate progress to get the health and social care money working much more closely together, so there is a focus on people’s needs rather than separate organisational budgets.  And we highlight the increasing workforce problems of recruitment and retention, and again it is very, very surprising that we do not have an up to date coherent national workforce strategy to address some of those really big problems of recruitment and retention.

But we also say that if the government, and successive governments have struggled with this, if the government is unable or unwilling to fund the system properly, it needs to be much clearer, and perhaps a different offer in which it’s clear that primary funding responsibility sits with the individual and families, and that is actually where we are heading at the moment, with a fresh policy framework that encourages people to plan ahead, and possibly uses incentives to make them do that. A far from satisfactory approach in many ways, but nevertheless this is the scenario that is upon us. And controversially, we suggest that again if the government is not prepared to fund the system adequately, it needs to revisit some of those powers and duties in the Care Act that have placed extra expectations and responsibilities on local authorities, so they are better aligned with what the government is willing to fund.

And not least we are back to the big question of what kind of care, social care and healthcare, are we all going to need in the future? What does it cost, where does the money come from? And with apologies to the Great British Bake Off, both the social care and the NHS, we can’t have our cake and eat it, unless we have got the right ingredients, and we have worked out how to pay for them.  And unless politicians are able to come together and develop a shared approach to how we tackle some of these long term problems, then the situation will just get worse and worse.  And I think that concludes our findings.  Thank you.