We are used to seeing catastrophic headlines and quotes about the NHS and social care, but it is never very clear exactly what is envisaged in the warnings. At what point are services considered to be in complete collapse? And has it been reached in light of the failure of services documented in the new Care Quality Commission report? Do they need more than just a funding boost and what are the implications of funding being targeted more at social services than the NHS, which is the political and organisational status quo?
The State of Care
The Mirror story reports that the ‘crisis in social care’ has led to contracts being handed back to local authorities by private firms that say funding is insufficient to provide safe care…..The NHS inspections, on the other hand, show that ‘quality of care has been maintained’. The article quotes the CEO of the NHS Confederation, ‘if social care goes down, we all go down’.
The CQC report rates the NHS, social care, mental health and GPs separately. In each of those areas there is cause for concern. There is a shortage of beds in both the NHS and social care, a need for more GPs, an increase in older people with needs that aren’t being met and unpaid family carers who are struggling sometimes for years without respite.
Some of the statistics:
- 2 million older people with unmet needs up from 1 million last year. That is 1 in 8. This has increased by 18% since last year and is a 48% increase since 2010.
- Number of beds in nursing homes down by 4,000 in the last two years.
- January -March 2017 highest ever acute bed use at 91.4% of capacity, when the recommended maximum for safety and effectiveness is 88%.
- 40% of unpaid carers have not had a break in more than a year and 25% have not had a single day away from caring in 5 years. This has caused a breakdown in carers’ own health with 78% reporting a deterioration in their mental health and 68% in their physical health.
- April – September 2016 60% of GP vacancies remained unfilled for more than three months.
- There has been a ‘steady rise’ in people using mental health services, but a 12% drop in psychiatric nurses in the last seven years.
Total of services designated inadequate or requiring improvement:
- Adult social care 20%
- NHS acute core services 40%
- Mental health core services 25%
- GP 8%
These figures show a serious shortfall in staff and beds, ie a shortfall of inpatient provision and a lack of support and care for both older people and their carers in the community. The result is two services struggling to keep up to standard in an integrated system which is described as designed to enhance both.
NHS England’s 5 Year Forward View
The picture the CQC statistics paint is one which should cause alarm not just in itself but because of the nature of the restructuring of the NHS which is currently in progress, turning NHS England’s 5 Year Forward View into reality. The Accountable Care Organisations, the US based system being introduced, depends on more care in the community, more volunteer, friends and family and peer support, and fewer acute beds in fewer, but larger, hospitals. And despite the evidence from the CQC report being that more people are developing chronic illness, including those who currently dedicate their lives to family and friends as volunteer carers, the success of the restructuring hinges on the population having healthier lives and being more self-sufficient for their health needs.
The report lacks a thoroughgoing analysis of the structural elements which are needed to continue to provide an effective health and social care system. There is scant evidence provided that continuing down the path of reducing NHS services on a hypothetical future reduction in demand will work. Indeed, there is a contrast between the stark statistics and the report’s commentary which focuses on strong leadership, innovation and technology as the way forward rather than the underlying reasons for those statistics.
The effect of privatisation on social care
In contrast to the CQC’s report, the Centre for Health and the Public Interest’s (CHPI) comprehensive report into adult social care in 2016 looked not only at the restriction of state funding and the resulting impact on NHS services but also at the startling long-term trend of the privatisation of provision. The report suggests that whole-sale privatisation has caused significant problems that cannot continue to be ignored. The CHPI says, “Worryingly, the early talk of a ‘mixed economy of care’ with local authorities, private and voluntary sector competing on a level playing field rapidly disappeared from political discourse.” Its statistics show the extent of the takeover by the private sector from local authority and NHS provision, “In 1979 64% of residential and nursing home beds were still provided by local authorities or the NHS; by 2012 local authority share was 6%; in the case of domiciliary care 95% was directly provided by local authorities as late as 1993; by 2012 it was just 11%.”
This trend illustrates the potential for the NHS despite arguments about the source of provision being presented as being of less importance than the headline issue of free at the point of use. The reality, in the face of inadequate public funding, is that the fees of private patients in the care system are used to cross-subsidise the public sector. Some contracts have been handed back to local authorities on the grounds that insufficient funding compromises care. It may, of course, also compromise profit.
The CQC’s statistics show that 1 in 8 older people have unmet social care needs which is a 48% increase since 2010. The CQC report does not say whether the unmet needs are greater in those who depend on public services than on those who have the means to pay. However, it is reasonable to assume that the 25% of unpaid carers who have not had a single day away from caring in five years and whose voluntary work plasters over the cracks of this collapsing system will be in that situation as a result of a lack of funds and therefore are dependent on diminishing public services. However in its 2015/16 report the CQC stated that ‘social care’s tipping point would be where the deterioration in quality would outpace improvement with a significant increase in unmet need’. Does a 48% increase in 7 years demonstrate that the tipping point has been reached?
Our concern overall is that the indicators are that we currently have a two-tier system in health and social care in this country and there is evidence that this is heavily influenced by the source of provision. As private provision expands the criteria for public services become more stringent and access to and funding for services is reduced. This analysis is supported by the CHPI’s report into social care and our own research into the rise in private income and provision in NHS hospitals since the Health and Social Care Act in 2012, reported in The Independent on 30 September NHS Privatisation Exposed: scale of treatment for paying patients at NHS hospitals revealed.
A renewal of public service
Bringing the NHS back again into the public sector (see nhsbillnow and nhstakeback for campaigns on this issue) and providing the right level of funding for the service would create the best framework for a return to the provision of universal and comprehensive services. What should be reignited – and what has been lost – is Aneurin Bevan’s principle that care should be delivered by clinical need and not ability to pay.
On the question of social care, the CHPI’s statistics on private ownership and provision of services create a more complex problem to solve. To quote that report, “There would be significant costs associated with workforce remuneration and development, as well as restoring service capacity and infrastructure to local government.” The privatisation of the NHS is less advanced than the privatisation of the social care sector. There is competence and capacity in the health sector to restore public service. But the long-term dismantling of social care capacity in local government complicates the issue. Again, to quote the CHPI, “What is more feasible is a two-pronged approach – a gradual resumption of the statutory and third sector role, and the imposition of a new, more equitable, business contract on private company providers.”
The extent to which social care is seen to be in the private sector competitive arena rather than in the public sector is illustrated in The Mirror article which quotes Alex Hayman of Which? magazine, “Our research shows a shortfall of 42,000 care home places by 2022.” If social care were primarily a public service concern we would expect this to be an issue that would be referred to the Department of Communities and Local Government but Hayman continues, “It is essential that the Competition and Markets Authority makes recommendations.”
Throughout its report the CQC recommends the 5 Year Forward View and Accountable Care route as the overall solution to the problems of the NHS and social care. But, in its failure to properly address the root causes of its own grim statistics, the CQC’s report should be taken instead as a wake-up call that the NHS may indeed not be fit for purpose by its 70th birthday. If this route is continued and the ‘mixed economy of care’ follows its current path to privatisation the evidence points to increasingly damaging consequences for standards of care and further undermining of the principle of universality.