"I wrote the following article back in March of this year and on reading it thought what has really changed.I wrote the following article back in March of this year and on reading it thought what has really changed.Additional funding has been made available but depending on where you are the access to funds ranges from very easy to ridiculously red tape burdened torture. For purposes of clarity additional funding to meet additional costs and not a simple giveaway.Some of the punitive billing models (per minute billing) have been switched off, but only to return when cost saving moves back up the priority list.Recruitment is flourishing due to the general employment situation; however the reality is this will be a short term impact and when normality begins to emerge underpaid and undervalued care jobs will once more tumble to near the bottom of the jobs people would like to do list.The importance of a modern IT solution has been highlighted and will prompt the reluctant to spend small businesses to look at what are now affordable solutions. If run properly these save money as well as reduce business risk."
Social Care, what's that?
There is some sort of natural desire for people to want to live well and independently at home for as long as possible. Preventing unnecessary admissions to care homes and hospitals, should be a priority in a modern civilised society and if it is to be delivered as a priority it needs to be recognised properly for what it achieves, and funded at a level that reflects this. Supporting people to live at home, as far as possible, would be an intelligent and cost-effective strategy for the nation’s health and well-being, however before this is possible there needs to be some sweeping changes to accommodate its role in society going forward. Some aspects are practical whilst others may be seen as more image and reputational management, moving from being the poor relation to being recognised properly as a key player in a wider integrated Health and Social Care is not going to happen overnight.
The practical would be a properly funded system as part of a wider integrated Health and Social Care framework, whilst a more full and accurate portrayal of its role may improve the perception about what it does.
However important the longer-term plan is, the question of the moment is “How will an already beleaguered service survive the Covid19 crisis?”
Ironically I first sat down nearly three weeks ago to write this article, as nothing contained within it is new, and for many people working on Social Care it will not contain any surprises, but for others it may give some insight and substance to the high profile media storm of the last few weeks concerning social care.
Ignoring the Covid19 crisis it has widely been recognised that some parts of social care sector were broken and on the brink of collapse. The ways in which it can be fixed have been discussed extensively, by health and social care experts, however ultimately it is all about money. Practitioners do not particularly like talking about the financial environment in which they have to operate, but it is the variable which enables the “What is to be done” to be delivered.
Funding is a wider social question as to who pays, the state or the private individual, or more likely a solution somewhere between the two. The political importance of this was seen clearly seen in the run up to the General election of 2017, when Theresa May tried to address the issue when she talked about the “Dementia tax”. This was seen as an electoral disaster and was soon managed out of the spotlight as it caused short term mayhem in the polls. This was and is still seen by many as key reason as to why the Conservative majority was unexpectedly reduced, by a Labour opposition that at one point was perceived to be unelectable. This ultimately caused the Prime Ministers demise as the reduced majority made the delivery of Brexit impossible. In fairness to her she was simply addressing a can that had been kicked that many times up the road that it was hardly recognisable as a can. However, talking about increasing taxes or people who have paid their taxes all of their lives having to sell their houses to pay for care, and deny their families what they see as their right of property inheritance is akin to political suicide. Since that election nothing has really changed, the challenges of an ageing population are still the same and the promises of review and reform continue. The inaction pre Covid19 was starting to become embarrassing, but with what has happened in the last couple of months many providers may not survive financially.
There is no doubt that post Covid19 many aspects of life will change; many businesses will disappear and people’s behaviour in terms of work and social activities will change. How that will pan out exactly no one can really say, but as part of this the debate on the whole area of health and social care will be taking place in a somewhat different environment. It is all well and good lauding the NHS and all of the other front-line care staff in Nursing Homes and Domiciliary Care in a time of crisis, but will that goodwill be maintained when it comes to addressing funding and the future of care in this country.
The Historical Background
As the poor relation, homecare is usually at the bottom of government and other decision-makers priority lists, perhaps also because it is less visible than services delivered in care homes and hospitals as well as being a very dis-aggregated business. The image is of low paid staff delivering a poor service by private companies only interested in making money. Of course, elements of that will be true but it is not really a fair reflection of how the service really works and the challenges it faces.
In the mid 1990’s I was working as an accountant with a large care home provider, and through an acquisition came across a domiciliary care business for the first time. It was really an add on to one of the homes in the acquired group, it was small, poorly organised, regulation barely existed and made no money. This was “Home Help”. At this time, such support was mainly delivered by in house Local Authority teams and the service was predominantly supporting elderly people in their own homes in need of shopping or some domestic tasks. The amount of “Care” was limited as that was the job of the District Nurse and the Health Service.
However the 1990’s was the decade of change for the care industry as the realisation of the ageing population was just starting to create a problem that the old style converted Victorian like care homes and the low level Home Help would not be able to cope with. Through government legislation Local Authorities would cease to be providers of care and become purchasers of care, as the future explosion of demand could never have been dealt with by the infrastructure in place.The whole landscape would change, it would have to change. The Local Authority run care homes would not be able to cope with the numbers, the properties were generally outdated and in a poor state of repair. The Home Help services were poorly run and expensive and would not be able to cope with increasing numbers as well as having to look after people in their own homes with increasing care needs.
The facts and the fallacies
- The historical shackles of the image of Home Help needs to be dumped, Homecare workers deliver a wide range of support services from the preparation of meals through to personal care and support with medication.
- Equality with NHS – social care is the poor relation and until the time comes that carers can be employed on similar terms to the NHS (pay rates, holiday entitlement, pensions and sickness benefits) and receive similar recognition, then recruitment is always going to be difficult. Social Care needs to be brought within the care loop and not just seen as an external source of support when it suits.
- The role of the private sector. Simply mention the private sector in terms of healthcare and the reaction is profit taking and exploitation. There will be examples to support such a view, but they are in the minority, public sector services are not always good and private sector services are not always bad. In terms of social care if the service was moved back to the Public Sector it would be a little like the rail industry going back to British Rail, nostalgia is one thing but actually it was not very good, and to bring such a service up to quality would be a very expensive option.
- The providers of social care are mainly private companies, although there are many not for profit and charitable providers. This is understood by most people, however GP surgeries (seen by many as the backbone of the NHS) are not part of the NHS in the way that hospitals are. Most surgeries are still small businesses. In most cases the Doctors own or rent their own premises, they employ and pay their own staff and have all the usual responsibilities of running a business. As part of this they aim to make a profit. The truth is that GP services are probably more privatised than social care.Zero hours contracts- most of the provision is probably delivered by employees employed on zero hours contracts. Such employment contracts are generally seen in a negative light and as a means of employers exploiting their staff. In some sectors and with some employers that certainly is the case. However interestingly I have spoken with many carers on the subject and I was somewhat shocked when nearly 80% of those spoken to were happy with the arrangement as for whatever reason it suited their circumstances.
- Commissioning (mainly through Local Authorities) drives the service, it is Commissioning that requests 15-minute visits, it is commissioning practices that means that there is a predominance of zero-hour contracts in the industry. The media tends to relate and blame these negative factors to providers when it is down to those who commission the services.
So Where is the Domiciliary Care Sector now?
State-funded homecare providers entered the COVID-19 pandemic in a severely weakened state, after decades of under-funding by successive national and local governments. Funding by Central Government has been cut through the years of austerity, whilst Local Authorities have been facing ever increasing demands on their services, as not only have we an ageing population but the consequences of austerity are causing further pressures to the needs of social care.
The recruitment and retention of staff is a major problem, terms and conditions for the workforce delivering state-funded care are very poor, with at least 50 per cent of care workers on zero hour contracts and many receiving wages on, or just above, the National Living Wage (NLW).
Many care providers have handed back poorly funded Local Authority contracts, the rates paid being commercially not sustainable. New entrants to the sector tend to avoid council-funded care entirely, planning to supply private individuals willing to pay a sustainable price.
The industry was already at breaking point and the trauma of the Covid19 crisis could prove to be critical.
To help mitigate financial pressures due to the COVID-19 pandemic, central government gave £3.2 billion extra funding to Local Authorities in England. The expectation was that councils would use a substantial proportion of this to support social care providers. If this comes through to support providers only time will tell, and different Authorities will give different levels of financial support.
There are two key elements of increased homecare provider cost pressures during the Covid19 pandemic:
- The costs of PPE. Generally, the costs of PPE in normal times in Social Care are low. Protective gloves are used but the need for aprons, facemasks etc. are relatively low. However, during the pandemic, the rules of the game have changed and suddenly the need for all forms of PPE has increased to a level never envisaged, and the unit costs (subject to availability) have multiplied 10 and 20-fold. For many businesses this has been an unfunded additional cost.
- The additional costs of sickness and absenteeism. The government may have put in place some measures for businesses to recover statutory sick pay, but this does not apply to larger providers.
If these are not addressed in a fair and equitable way the reality is that providers will fail financially, this short term issue must be addressed and whilst some of the rhetoric of support is out there, the proof will be what remains of the Social Care system from a providers point of view post Covid19.
My fear is that if Local Authorities do not get funding to these companies they will fail, ADASS (Social Service Directors) have sent out the right messages to Local Authorities. They have asked for services to be paid on a planned hours basis as well getting monies to these companies to help them through the crisis. The response from Local Authorities will be varied and with so many small businesses not having the financial support and know how to help steer them through this will inevitably see many businesses fail.
However, it is the long-term funding and the framework that it operates in that is the real challenge, what will society want in the future in terms of social care and how will it pay for it?
Phil Talbot is a Chartered Accountant having worked in various senior finance roles in Health and Social Care for the last 30 years. Sixteen years of this as CFO of one of the largest providers of domiciliary care in the UK. He now works with an emphasis on supporting businesses within health and social care looking to provide FD type support for businesses that need help, but not the full-time reliance on such a person. This can involve any aspects of the business but with a focus on accounting processes, reporting and the development of budget and forecasting models for business development, as well as helping owners in preparation for business exit.For any enquiries please contact Phil Talbot on 07967 640082 or email firstname.lastname@example.org