COVID-19 has thrown social care in England into the spotlight in a way that nobody would have wanted. The death toll in care homes, in people’s own homes, and among care staff. The desperate early struggle to get personal protective equipment to carers that mirrored the problems in the NHS, but at times seemed worse. The heart-wrenching position of care home residents denied contact with their loved ones.
But also, as a small silver lining, a greater grasp among the public – at least as measured by media coverage – and indeed a greater grasp within the NHS itself, of the importance of social care and the need to integrate it better with health: along with the desperate need, in the Prime Minister’s words, to “fix” it.
The structures of the National Health Service can at times seem a little bewildering but it is simplicity itself compared to the mind-blowingly complex world of social care. Social care is commissioned by 152 local authorities – a small amount is commissioned by the NHS – from some 18,000 organisations with 34,000 establishments, almost all of which are either private or voluntary sector organisations. It is a hugely tangled mix of public and private funding, of fees and of top-up charges, and of care that individuals and families pay for themselves. Half the budget goes on adults of working age as opposed to older people, although one would not know that from much of the public discourse, any more than most people would know that it has a workforce larger than that of the NHS. Lacking the highly visible public buildings of schools and hospitals, or even of GP surgeries, it is much of the time invisible. Much of its work is aimed at ensuring that people can live as independent a life as possible but it is inevitably conjoined to the NHS and essential to the service’s smooth operation – keeping people out of hospital in the first place and enabling swift and safe discharge when their immediate medical needs are met. But there can be bitter battles that bewilder relatives over who pays for what when it comes to those with the greatest nursing needs, and whether a need is “social” or “medical”.
Making this labyrinthine world function well is clearly a challenge, and recently the King’s Fund set out to ask where does leadership in social care lie? How effective is it? What might be done to improve it? Two of us interviewed more than 40 people in diverse parts of the country ranging from local authority Directors of Adult Social Services, to service users, assorted providers and a limited number of more national figures. While that is hardly a fully representative sample, this is what we found.
That, more often than not, the more local the leadership, the better. This ranged from carer’s initiating changes in service to adults of working age in particular holding personal budgets that gave them the ability, singly and jointly, to arrange the services they need. Councils that actively sought and supported feedback – from service users and from providers – were themselves valued. The best organisations seemed to cherish such engagement, the poorer ones tending to hide from it. As with the NHS, we heard of much variation around the quality of care and services, and, again as with the NHS, much depended on personal relationships and the ability to understand the other side’s problems and seek to address them.
Where there was almost universally withering criticism was of the Department for Health and Social Care, where, until very recently, the role of a Director General for Social Care has gone missing. Interviewees complained of a “vacuum” of leadership nationally and “a really quite astounding lack of understanding of social care at the centre.” The department does now seem to be addressing that, but our interviewees were clear that there is a way to go.
Given our small sample size, we were reluctant to make recommendations but we have put forward ideas for debate. There is a desperate shortage of training and career development in social care at all levels, certainly compared to the NHS, with expenditure averaging about £14 per head. What, one might ask, can you buy for that? Despite repeated government promises to improve matters, there is a lack of good data on social care – on workforce, market stability, the outcomes of care and cost-effectiveness, with the lack of data inhibiting research. There are options available to take some of the heat out of the annual battle between councils and providers over fees, and a case for the myriad trade bodies and other organisations that represent social care coming together to provide less cacophony and more of a single voice for social care. There is also a case – as the government now appears to be proposing as part of its NHS legislation – not just for improved data but for an assessment of how well local authorities, and indeed the NHS, are delivering social care. Not, in our view, so much as a means of policing them as one for strengthening the hand of those responsible for social care amid squeezed local government budgets, and as a means of highlighting and spreading best practice. All this, we argue, might make leadership in social care easier.
Good leadership matters. But it can only get one so far in an underfunded system where the “fix” to social care has been long promised but seems to be forever just around the corner. But the good news from these interviews was that most of those we spoke to believed the integration of health and social care is making progress. And while our focus was on long standing issues in social care, there were reports that the need to act swiftly during the pandemic had both broken down barriers and led to a better understanding in at least parts of the NHS of the importance of social care. The worry was whether, as the pandemic eases, that will last.
Richard Humphries Nicholas Timmins
Richard Humphries and Nicholas Timmins are senior fellows The King’s Fund.
Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.