Survival of the social care cheapest?

24 Apr 12
Claudia Wood

The latest shocking revelations about abuse of elderly people in the social care system raise unanswered questions about funding, training and leadership

It is a well-known fact that the social care system has been under-funded for many years. We've had so many warnings about unmet need and the funding gap that statements about the size of the current funding shortage (estimated to be £500m this year, £1bn by 2013 and £6bn within 20 years) don't raise many eyebrows.

They certainly haven't prompted the four successive governments since the 1999 Royal Commission to grasp the nettle and come up with a new funding regime. But numbers – however large – don’t often provoke an emotive response.

What has moved the public and politicians, however, are the individual cases – of older and disabled people abused in care settings, and of people left unsupported and alone at home waiting for agency carers who never come. However it is very hard to blame the shocking cruelties of a handful of staff at Winterbourne View and now Ash Court care homes on a shortage of funding, particularly given the healthy fees we know they charge. If anything, they show that all the resources in the world won’t guarantee quality care if culture and leadership aren’t right.

Anyone who has first-hand experience of the care system knows that for every cruel and sadistic 'carer', there are dozens of dedicated and devoted professionals. For this majority, the culture and leadership are right – and they valiantly support vulnerable people in the face of a widespread lack of resources. But how long can this go on?

There is as a 'long tail' in both residential and domiciliary care in the UK: a few large providers with well-known brands and multiple NHS and care contracts operate alongside a vast number of very small, very local providers, caring for a handful of people each. These small fry often rely on local authority block contracts for the majority – in some cases all – of their income. For them, the reality of living in a monopsony (where there is only one dominant purchaser of a service) means local authorities can use their purchasing power to set fees (perhaps below market prices), dictate contractual terms, and arrange bidding wars between providers to exert downward pressure on prices.

Sarah Pickup, the new president of the Association of Directors of Adult Social Services, drew a line in the sand on this state of affairs last week, stating that social care providers needed to stand up to local authorities and refuse to bid for care contracts where they judged the prices would not enable them to deliver the specification.

But in a monopsony, this is easier said than done. When a small care agency relies on a single bloc contract for its income, refusing to bid means putting itself out of business. It would take a brave care agency to count itself out of the race and rely on its competitors to do the same. This prisoner’s dilemma is even less viable given that the care market is so fragmented and diverse – an entire local care market uniting and all agreeing not to bid seems unlikely, given that big providers – benefiting from economies of scale and financial reserves to take on loss-leading contracts – are also in the mix.

The more likely scenario is that providers will remain on the bidding treadmill until personal budgets break up the monopsony and individual contracts replace blocs. But many areas are – geographically and figuratively – a long way from the personalisation rhetoric so readily available in Westminster. Just 4% of care users in Somerset have personal budgets.

So in the interim, providers are faced with cutting services to the bare bones, delivering 15 minute care slots, struggling with staff recruitment and even more with retention, and cross-subsidizing from private clients (if they are lucky enough to have them). It would be a vast generalisation to suggest the abuses uncovered at Winterbourne View and Ash Court are a direct result of a funding shortage – poor pay does not make someone cruel. And we should remember these scandals are not reflective of the quality of care today.

But at the same time, we must face the fact that there are entrenched staffing shortages in the care system, a pervasive sense of being undervalued, and carers still being asked to deliver 'time and task', rather than a level of support. Despite providers’ best intentions, the quality of care and the preservation of dignity is eroded. It might not make it on to the BBC's Panorama programme, but this gradual, widespread decline is the real human impact of an unaddressed care funding gap.


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