Reform Analysis: Adult Social Care Reform White Paper
Yesterday saw the publication of the long-awaited adult social care White Paper: People at the Heart of Care. While September's social care announcement focused on the funding model (we at Reform were not fans), the White Paper, we were told, would answer the many outstanding questions about the delivery model.
The first thing to say is that the vision and ambition is spot on. As the Secretary of State for Health and Social Care states in his foreword, social care must put "people and families at its heart". This vision is underpinned by three objectives:
- People have choice, control, and support to live independent lives.
- People can access outstanding quality and tailored care and support.
- People find adult social care fair and accessible.
A series of statements that the Government wants to be true as a result of their 10-year vision essentially provide the metrics for success, and they are brilliantly human and outcomes focused.
However while the vision is great, the plan for achieving it leaves much to be desired, with too many areas underdeveloped — perhaps unsurprisingly given the limited additional funding over the next three years.
In our analysis we've focused on four keys areas: ensuring a healthy, competitive market; improving quality and delivering that user-centric vision; strengthening the workforce; and harnessing data and tech. As you'll see, on all but the last topic we think there's much more to do.
Shaping a Healthy Care Market
The White Paper rightly states that: "High quality, personalised care and support can only be achieved where there is a vibrant, responsive market of service providers." It also rightly notes that low fee rates and funding uncertainty creates market fragility. However part of the new approach to funding social care is a commitment to ending the cross-subsidisation of local authority funded care home places by self-funders, which, as we flagged in our previous analysis of the funding model, risks increasing market fragility by reducing funding even further. It's worth noting that analysis by CSI Market Intelligence found that, in 2019, two care homes closed for every new home that was opened. The Government's pledge to move "towards paying providers a fair rate for care" is therefore not just welcome but essential.
Sadly, there is no plan for how this will be achieved, and with local authorities already struggling to pay for rising social care demand — and needing to fund the 6.6% increase to the National Living Wage announced at October's Budget — this could be devastating to the sector.
The Government will argue that enabling people to remain in their own homes for longer, and investing in prevention, will help reduce costs, and it will, but that will take time. In the meantime, more providers are likely to go bust, leaving those needing care with even less choice (the opposite of the Government's ambition to increase choice and control).
Steps to increase oversight and accountability via new powers for the Care Quality Commission and Secretary of State, and £70 million of funding over three years to boost local authority "market shaping" capabilities, may be good moves, but they will only make a difference if there's a decent market to shape and oversee in the first place...
Delivering Quality And Person-centric Services
Despite welcome nods to "person-centred care" and giving genuine choice and control to social care users over the support they receive, the White Paper is light on detail on what this will look like in practice.
Steps will be taken to make it easier for care users and their families to navigate what is currently an unwieldly system. Information on the support available to those in need of social care is fragmented and difficult to interpret, so collating and signposting resources on a single website is positive step. But there is a big gulf between helping users understand and navigate the current system and empowering them to design the personalised support they desire.
A similar logic applies to the use of data to improve the quality of social care services. Better data collection on care needs might help local authorities detect unmet need and enable care workers to provide more personalised support, but more knowledge on what is going wrong alone won't lead to the improvements in care quality the system needs.
The crisis in care quality stems from two key failings: inadequate funding which leaves only those with the most substantial needs eligible for support, and the inability of care users to truly shape the services they are offered. In both these regards, the White Paper is lacking in concrete proposals.
Moving beyond standardised models of care will mean embedding co-production into the design of the system itself. Existing models such as the use of direct payments and personal budgets could help here, but today's announcements do little to reimagine the relationship between those needing care and those providing it.
Strengthening The Workforce
Recruitment and retention will be pivotal as the Government expands the social care workforce to meet the growing demand for care services. One essential blockage is the lack of esteem care services currently receive, relative to health services. Thankfully, the White Paper acknowledges that adult social care must become a "more competitive and attractive sector to work in" if the workforce is to grow at the required rate. Yet the Government's answer — focused mostly on accreditation and the transferability of care qualifications — whilst important, misses the mark.
It is true that a lack of career structure, in-work progression and training are regularly cited as reasons for people leaving, or being sceptical about joining, the profession. But the elephant in the room for the attractiveness of social care work is pay. Social care workers are thought to be paid £7,000 less a year than support workers in other publicly-funded sectors with equivalent skill sets.
With 30.4% of the workforce leaving the sector in any given year, more must be done. As the White Paper rightly says, social care recruitment tends to be "hyperlocal", carried out by Local Authorities that have a better understanding of local labour markets and future demand. With many councils under financial strain, however, funding higher pay looks unlikely without a significant injection of new cash.
Harnessing Data And Technology
By far the most tangible sections of the White Paper relate to better use of data and technology — and on this at least the Government should be applauded. Data collection in the social care sector has been notoriously poor, an issue exposed by the pandemic with the absence of basic information, such as how many people were in care homes, creating huge problems.
The commitment to establish an "adult social care data framework by spring 2022, setting out what data the sector needs to collect, the purpose of those collections and the standards it is collected to" is very good news. Better data should mean better decision-making, especially as the Government has also committed to moving from aggregate to anonymised, client-level data over the next three years, enabling different health datasets to be linked.
The Government has set a target (hallelujah!) to ensure that "80% of social care providers have a digitised care record in place" by 2024. Comprehensive data on service capacity alongside digital care records would be a massive step forward.
The White Paper also makes welcome promises on technology. £150 million is earmarked for digital transformation to help people "live independently in their own homes for longer" by "testing ideas" and scaling those "where there is proven benefit". In the short term, this funding will be available for technology to help reduce falls among the most vulnerable 20% of care home residents, via remote monitoring technology. Staggeringly, falls among the elderly cost the NHS £2 billion a year, on top of the potentially life altering effect for the individual. Deploying technology in this preventative manner is eminently sensible. Although it remains to be seen how far £150 million will go.
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