Social Care: It is about the money.

 This is the second blogpost where I’m revisiting the work I carried out from 1990 onwards - in the light of what has happened since.

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After Merry Cross and I carried out a review of the Boundary Road service for the London Borough of Camden in 1990 - the subject of my last blogpost - I was asked to do a review of “the range of living options available to disabled people in Camden in the 16-64 age group, and to help formulate user-led directions for future development”. 

The review focussed on interviewing a representative sample of disabled people to identify their current accommodation and access to support; and what their aspirations were for how they wanted to live their lives and the support they needed. 

The brief I was given stated that local health and social care services aimed “to work together to provide a range of living and care support arrangements which are varied and flexible enough to meet the needs of [disabled people] and enable them to have a real choice about where and how they live”.

Most of the resulting recommendations made to Camden’s health and social care services focussed on what needed to be done in order for disabled people to have access to the kind of personal assistance needed to go about their daily lives. They are the kind of recommendations to be found in so many documents when disabled people’s voices have been heard and responded to. At a national level, these voices and aspirations were most clearly encapsulated in the 2005 Independent Living Strategy, which drew on thirty years of campaigns for independent living and which was supported by both government and opposition at the time.

The Independent Living Strategy fell victim to the years of austerity after 2010 with most of its commitments unfulfilled. This was a result, not only of a reduction in funding to local authorities, the closure of the Independent Living Fund and so on, but also of a shift in the language and focus of public and policy debates on social care.

Government priorities are now couched in terms of speeding up hospital discharge by e.g. legislating to enable discharge from hospital without a proper assessment of support needs, and commissioning more ‘intermediate care beds’. 

A different narrative is offered by Social Care Future - “a growing movement of people with a shared commitment to bring about major positive change in what is currently called ‘social care’”.

We all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing things that matter to us.

These are the same aspirations that were being articulated by those I interviewed for the Living Options Review over thirty years ago. And even before that by people like Paul Hunt and John Evans, stuck in long-term residential care in the 1970s and 80s. 

And, as is evident from the brief for the 1990 review, Camden’s health and social services were motivated by a similar aim - to enable disabled people “to have a real choice about where and how they live”.

But today, there are so many barriers to people having that meaningful choice about ‘where and how they live’ if they need support to go about their daily lives.  Some of these barriers are the same as thirty years ago - such as the lack of suitable housing. Other barriers have got worse over the years.

For example, we thought that local authority budgets were squeezed in 1990. Today social care provision is suffering from the consequences of the years of austerity which followed the 2008 financial crash. By 2019/2020, local authority funding overall had fallen by 16% since 2010, largely because of a reduction in central government grants. The funding fell more in areas with higher levels of deprivation.

The gap between the tax-funded resources available for meeting older and disabled people’s needs for support, and the level of those needs, has grown year by year. Local authorities are increasingly unable to pay for the care they commission at rates which are financially sustainable for providers of care. The result, according to the Care Quality Commission and Care England, is that increasing numbers of care providers are handing back contracts to local authorities or refusing to take on such contracts in the first place.  

The consequences for the care workers whose organisations continue to take on local authority contracts is illustrated by the Conference organised by the Association of Directors of Social Services in the East Midlands, where providers were advised on how to refer their staff to food banks and how to access benefits to top up their wages. 

People who fund their own care and support find it increasingly difficult to find or pay for the support workers they need. At the same time, fewer older and/or disabled people are qualifying for publicly funded support. According to the Nuffield Trust, over the last few years, local authorities have tightened up their eligibility criteria and the means test has not risen in line with inflation. Moreover, when local authorities do assessments of the need for support they are increasingly using so-called ‘asset based approaches’ to direct people to rely on family members, neighbours and volunteers. And more and more requests for support result in no care being provided at all. 

Age Concern has estimated that in 2021/22 28,890 older people died while waiting for support. 

The social care sector continues to highlight the impact of low wages and poor working conditions on the level of vacancies and the Association of Directors of Social Services estimate that in 2022 an average of over 170,000 hours of homecare was not being delivered each week.

What do I conclude from all of this?  

Well, I would say that we’ve seen progress in that the language of the independent living and disability movements is generally more evident (even if it doesn’t always match the reality) and few would deny disabled people’s right to the same aspirations and opportunities as non-disabled people.  For older people progress in changing how we are seen is not so evident: a fact very evident to me now that I am both old and disabled in that it is my generally my age that prompts patronising language and low expectations. 

But even progress in disabled people’s particular ‘culture wars’ has not prevented a reduction in our chances of getting the support we need to go about our daily lives. 

And why is that?

During all our efforts to change the way support is delivered we often emphasised that it wasn’t necessarily about the money.  Indeed, in many instances we proved that it cost less to deliver choice and control in people’s lives than it did to confine them to settings and forms of support which denied autonomy and self-determination. 

In 2023, however, I have concluded that it is about the money. Social Care Future’s vision of what a good life looks like, the striving to continue to make progress of changing the way that people are supported - all of this is important.  But I can’t be the only one who fears that - unless we have significantly more investment in social care - such striving will be in vain. 

Disabled people were successful in our campaigns for direct payments - money to enable choice and control over who provided our support and how.  But if direct payments, personal budgets or personal health budgets are not sufficient to compete with the wages paid by supermarkets then access to a normal life is impossible.

The battle we haven’t won is for an increase in public spending on social care.  

The planned reforms to social care - initially introduced in the 2014 Care Act but yet to be implemented - would, if ever implemented, shift some of the costs of care borne by individuals onto public expenditure.  But they wouldn’t increase the overall amount spent on social care.

In my last blogpost, which focussed on nursing and residential care, I concluded that any increase in funding on that form of care would only make the sector more profitable for private investors with little impact on the quality of care or the working conditions of staff. In contrast, an increase in funding on care and support to enable people to stay living in their own homes would not only attract more care and support workers, it would also deliver what most people want.  Moreover, it would reduce the numbers having to go into the most expensive forms of social care. 

But today (4th April 2023), the government announced its long-awaited ‘work force plan’ for social care - which halves the amount of money previously announced as available for increasing and supporting social care workers.

It is hard to see what the future of social care is - and therefore what the future is for older and/or disabled people is - other than the continuing decline of a crisis-riven service.

Life is going to be harder and harder for those of us who need support - and sometimes life won’t be sustainable with such a lack of support. 

Social care may need more funding but it's more important to first look at where the money goes

Thirty-two years ago, in 1990, Merry Cross and I carried out a review of 48 Boundary Road, a residential service catering for disabled people of working age in the London Borough of Camden.

This had been a radical new service when it opened in the late 1970s in a specially designed building. It was intended to offer disabled people the kind of choice and control in their lives which was sadly lacking in more traditional residential services. As we wrote in our report: 

When the building was first opened in 1979, it quickly established a progressive and exciting reputation amongst both professionals and the disabled community….The early days of Boundary Road were part of a growing recognition of the rights of disabled people to live independently and the organisation did much to make this possible for a number of people.

Despite this, we found that - partly due to the poor design of the building and partly due to poor management - the service fell short of its original intentions. We concluded that “it has lost its way and there is a high level of dissatisfaction amongst both residents and staff”.

We recommended that the building was transformed into an Independent Living Resource Centre, with a small amount of residential provision which should only be for short stays.  It should be a base for services which would make it possible for young disabled people to live in homes of their own with choice and control over the support they needed to go about their daily lives.

Recommendations such as these fell on fertile ground in the 1990s, when the Independent Living and wider disability movements were gathering pace. Camden’s Social Services Committee accepted our recommendations. 

At that time, an increasing number of local authorities were making it possible for disabled people to have control over the support they needed by providing cash payments in lieu of services (direct payments) enabling them to live in their own homes rather than in residential settings.  The Independent Living Fund was also providing cash payments to more and more people and in 1996 direct payments for younger disabled people were finally legislated for by the Conservative government and then for older people by the subsequent Labour government.

So what happened to 48 Boundary Road?

Well, if you do a search for that address now, it comes up as a purpose built 100 bed nursing home. The original building must have been demolished sometime in the 1990s and I went down a veritable rabbit hole of trying to  establish the ownership and inspection details of the nursing home which was built on the site. As far as I can see it was initially registered as a nursing home in 2001 and passed through different ownerships since then.    

One owner was Southern Cross Healthcare, a provider of a large number of care homes which was taken over in 2004 by Blackstone Capital Partners, an American private equity business.  They expanded the business by taking over other care home companies and continued the practice of the previous private equity owner of selling and leasing back the properties, thereby releasing capital gains for the owners but increasing the overhead costs of running the services. In 2006 the company was floated on the stock exchange.

By 2011, Southern Cross was in financial difficulties caused by annually rising rents combined with a squeeze on the fees which could be afforded by local authorities and self-funders. It went into administration in 2012. 

The nursing home at 48 Boundary Road has had a variety of owners since then, mostly for only two or three years at a time.  Its inspection rating by the Care Quality Commission has never been great - in 2015 an unannounced inspection found five breaches of regulations; in 2016 the CQC found improvement but still one breach of regulations; in 2019 (under a new owner) CQC rated the service as inadequate; in 2020 (under yet another owner) two inspections rated it as requiring improvement.

When the building first opened as a care home it was called St John’s Wood Care Centre.  But in 2022 it re-opened, under yet another owner, as Hampstead Court Care Home.  It is marketed as being a ‘luxury care home’ in Westminster (though it is in Camden) and now has 82 bedrooms (down from 100) so presumably it has been refurbished. Like the previous care providers on this site it is registered for both older and younger people. Its CQC registered owner is Willowbrook Healthcare Limited but Avery Healthcare has recently welcomed it to its ‘portfolio’.

Public and political debate on social care has been dominated by two narratives - one that social care is in crisis because not enough money is going into publicly funded residential and nursing care (with one of the consequences being that self-funders are charged more and are thus subsidising local authority funded care); the second that people are being forced to sell their homes in order to pay for their care, with a particular emphasis on the injustice that some conditions attract funding from the NHS whereas others, particularly dementia, do not. 

However, instead of just focussing on how much money is going into social care, perhaps we should pay more attention as to where the money goes and what are the other factors responsible for both the cost and the quality of social care.

Privatisation of social care - both of care homes and of help provided to people in their own homes - was encouraged by the Conservative governments of the 1980s and 1990s and was part of the major reforms introduced following the 1990 NHS and Community Care Act which transferred funding for residential care from the social security system to local authorities.  All governments since then have continued the policy that the role of local authorities should be confined to commissioning rather than providing social care services.  

Today, more than 80% of nursing and residential home places are provided by private companies with some of the largest being owned by private equity firms. These companies treat their investments as high risk and high return, loading the businesses with debt and creating complicated ownership structures which often involve offshore registration and tax avoidance. During the pandemic, the profits of the largest private providers of social care increased while the gap between the pay of directors and that of workers widened. 

The investment companies who take over care homes tend to employ financial engineering measures which aim to extract a large sum out of the business by selling off and leasing back properties, taking out cash from the business on an ongoing basis, and/or increasing its value prior to selling it on. 

High quality services require a valued, well trained and stable workforce. Yet the social care sector is dominated by low pay, insecure and poor working conditions and this undoubtedly helps explain the high level of staff vacancies. That so many care-workers still manage to provide good care, when investment in many care homes is motivated not by a public service ethos but instead by how much money can be taken out of the business, is a tribute to the humanity of each of those workers.

If we don’t change the current model of how residential social care is provided there is a danger that any increase in funding will merely make the sector more profitable for private investors in residential and nursing homes with little impact on the quality of care or the working conditions of staff. Or indeed little impact on people's ability to remain living in their own homes, which is what most of us want to do.

Avery Healthcare, now the owners of 48 Boundary Road, was recently acquired by a joint venture between Reuben Brothers and the US real estate investment trust Welltower Inc.  The press release announcing the acquisition said it was expected to “generate significant future growth opportunities”.