Written evidence submitted by James Porter [ASC 039]
How has Covid changed the landscape for long term funding reform?
The system has been broken for many years and what this pandemic has done is to shine a light on its failings. Clearly the pandemic has made the work of social care much more difficult and has caused severe difficulties for those using the services and their families, particularly in the matter of visiting and social isolation. What has become clear is that the service is seriously fragmented and put to the bottom of the priority list as can be seen from the lack of PPE and the issues with staff sickness and how it is dealt with.
Covid has also shifted attention to the residential sector and away from domiciliary care. Goodness only knows how that sector has been coping as it seems to get scant attention in the media or in any of the Press Conferences. In fact, this sector is hugely important in the care of older and working age service users as by far the majority of people want to remain at home rather than go into residential care. It is important that this is well understood. It has been stated clearly by professionals and service users for all of my working life and for the 20 odd years that I have been retired but still never seems to be heard. In the matter of fragmentation, domiciliary care is in an even worse state than residential care and has been the subject of many concerns about zero hours contracts, lack of payment for travel time, sickness pay and generally poor conditions of service for those employed in the sector.
The funding priority should be to encourage domiciliary care although in the immediate term this cannot be at the expense of the residential sector. It has also become clear that funding is gravely inadequate and that attention needs to be given to providing a needs led service which actually meets the needs of those who use it rather than the companies who own the majority of the provision. This means that Local Authorities should be properly funded in order to meet the needs that are so evidently there and, in order to end the fragmentation, it is also necessary to understand that the majority of provision should be in public hands.
It is also clear that the greatest asset to any care organisation, the staff, are not only being placed in jeopardy during the pandemic but are also forgotten about or taken advantage of. If there is to be funding reform, a high priority has to be giving good pay, decent conditions of service, including the ending of zero hours contracts, payment for travel time and proper sick pay arrangements. It is equally important to ensure good staff development and training with a big emphasis on Continuing Professional Development. This can only be done through a service wide pay and service conditions structure which must apply to all employers, whether public, private or voluntary sector. This will undoubtedly lead to a drop off in private provision as even properly funded Local Authorities will be unable to pay fees which feed the profit motive. This should help to lead to the ultimate aspiration, that of the creation of a National Care Service provided free at the point of need. In any such scheme “hotel expenses” would need to be paid by service users as they would have to pay for those if living at home.
How should additional funds for adult social care be raised?
This can be done from a range of sources; additional direct taxation; the hypothecation of Inheritance Tax; closing legal Inheritance Tax loopholes; raising and ring fencing National Insurance and the introduction of a Wealth Tax. It is not possible to say to people that this can be done without raising further revenue but any government looking to fix this problem needs to be honest about this and also strong enough to ensure that any tax income raised is used exclusively for this purpose. The public is getting the message that there is a crisis in social care and would be prepared to accept these changes if they had a guarantee that the funds would be used for this purpose. Any suggestion that it can be done without raising further revenue is false and must be conveyed clearly to the public. The funds then need to be distributed through Local Authorities working closely with the NHS to ensure that goals are achieved and mutually understood.
How can the adult social care market be stabilised?
Everything that is wrong with social care provision in England is captured in this and the final question in this call for evidence. Social care should never be seen as a “market” with “competition” as its watchword. The only way to “stabilise the market” is to get rid of it. The whole sector suffers from fragmentation which is a direct result of the marketisation of the service. There is some evidence that the government understands this in its publication of the draft Health and Social Care Bill which sees an end to commissioning and competition and a rebooting of the idea that the way forward is co-operation. Whether this concept will survive the consultation process is another matter but marketisation has clearly failed the social care sector and should be scrapped. The evidence for this is abundant. Closure of care homes because they don’t make money. Local Authorities unable to fund innovation because what funds they have are being diverted to a private sector which is not capable of meeting the demand because there is no strategic plan for social care coming from the centre. Service users unable to fund their own care and so either going without or being placed in an ever extending queue as eligibility criteria are tightened. The answer is to move towards a National Care Service provided free at the point of need and largely within the public and voluntary sectors. This also will require robust regulation and my personal view is that there should be a regulator which has a clear remit for social care and therefore needs to be separated from the current CQC.
How can the adult social care market be incentivised to compete on quality and/or innovation.
See above. Quality and innovation does not come as a result of competition. Competition, in the main has seen a race to drive down costs and expecting providers to make do with less and less. And if you drive down costs you drive down standards. Innovation in social care has largely come from Local Authorities, the NHS and the Voluntary Sector. In all of my 31 working years and my 20 years of retirement, where I have taken a keen interest in the development of services through my involvement in the Voluntary Sector and through consultancy work, I am yet to see an example of innovative work emanating from the private sector. That does not mean to say that there is none; simply that I have not seen it. As examples of this, the development of Housing with Care for older people and Supported Living for working age adults has all come from work done in the public sector. My experience is that private sector providers do not see this approach as making money. The idea, therefore, that competition leads to innovation is false, at least in my experience.
Incentivisation can only come from there being a clear strategic plan that shifts provision gradually from residential to domiciliary care; that encourages Housing with Care and Supported Living and that recognises the huge task in providing services for those with varying levels of dementia.
It is also vitally important to recognise the work of carers, particularly those unpaid and unsung heroes - family carers. The plight of family carers is a national disgrace and a comprehensive plan to recognise their work and provide proper payment to them is essential.
There needs to be a national strategic plan which takes account of all of the following
We need to gradually shift priority from residential to domiciliary care and to encourage housing with care and supported living arrangements.
We need to aspire to the creation of a National Care Service provide free at the point of need and provided mainly in the public sector. A National Care Service is not the NHS and although there should be close and collaborative working, care is best provided in the community and through Local Authorities.
The marketisation of social care needs to end, as implied in the draft Health and Social Care Bill.
We need to understand that funding can only come from taxation and this requires a commitment to consider all forms of taxation including income tax, national insurance, inheritance tax and a wealth tax. Nothing should be off the table and an informed public debate must take place over this.
Staff need good pay, good conditions of service and a commitment to training, staff development and continuing professional development. This can only be achieved by the creation of a national structure, applicable to all sectors and strong links to further and higher education providers.
There should be national recognition of the work of family carers and a commitment to supporting their work through proper benefits, provision of decent respite services and a support network.
All of this should be underpinned by a “stand alone” regulator separate from the NHS and the current CQC.