The fragility of the social care system was utterly exposed by COVID. The decision to discharge elderly people into care homes in the early days of the pandemic is seen by many as one of its biggest scandals – but delays in making vital resources such as testing and personal protective equipment (PPE) available to staff also had a huge impact.
More than 40,000 people are thought to have died in care homes in England and Wales due to COVID, with many harrowing accounts of residents being “locked away”, or dying alone with families forced to stand outside.
A staffing crisis, leaving the sector short of over 165,000 carers, led to some homes being declared closed to new admissions – the knock-on effect of which has been hospital bed blockages and people going without the care they need.
Despite government after government promising to get a grip of Britain’s care service, some argue the system is in a worse state than ever. The emergency funding that was funnelled in to prop up the sector during COVID dried up long ago and there have been accusations about that money being mispent, as it allowed private companies to prioritise profit over care.
The fragmented combination of public and private care is a hugely complicating factor. As is the army of “invisible” (largely female) carers working – unpaid – to support family members and friends at home, without acknowledgement or support.
The NHS cannot be fixed unless the care system is transformed. But how?
How did COVID expose the full inadequacy of the UK’s care system?
Adelina Comas-Herrera: COVID had a particularly cruel impact on people who rely on care from others and the people who provide that care, paid and unpaid. The disproportionately high number of deaths among people living in care homes was the most visible and tragic impact, a compilation of international data showed that in the UK as many as one in ten residents in care homes were likely to have died from COVID. While many people in care homes are close to the end of their lives, by September 2020, in Scotland alone, care home residents had lost 5,600 years of life due to COVID.
One care home manager who was questioned in a study about how the pandemic affected end of life care in the UK put it this way:
It was terrible. It was undignified. I would use such a strong word as traumatic for both myself and my staff. It was definitely traumatic for the relatives we know.
The scale of other impacts on the physical and mental health of people who rely on care and support are even more difficult to measure, as in the UK we do not have baseline data to enable us to compare what it was like pre-pandemic. But many studies now have highlighted distress and trauma among residents and their families as well as care staff.
To mark the 75th anniversary of the launch of the NHS, we’ve commissioned a series of articles addressing the biggest challenges the service now faces. We want to understand not only what needs to change, but the knock-on effects on other parts of this extraordinarily complex health system.
From the same study, a registered nurse spoke about how how care home staff had done a “brilliant job” but they were overworked and undervalued, adding:
It was horrendous. It was distressing. Even though the work they’ve done is unbelievable, I don’t think the government or society has particularly placed any massive accolade on the work that the care home staff have done …
How broken was the system before?
ACH: The social care system in England was in bad shape before COVID. Cuts to local authorities funding in previous years had undermined the system’s resilience, resulting in high reliance on unpaid care by relatives and others, staff shortages, outdated buildings being used as care homes and poor data and information systems.
In the immediate aftermath of the pandemic, there has been a staffing crisis. It is now getting to the point where a lack of staff has resulted in providers having to withdraw their services and the care regulator expressing concern over the safety of services due to persistent understaffing.
The social care system loses staff to the NHS, which offers better pay and conditions. Long-standing issues of low pay and poor working conditions have not yet been addressed, despite the context of high inflation and a cost of living crisis, and this is in addition to staff working in this sector having experienced high levels of stress, as illustrated in this quote from a study of the experiences of care home managers:
I think that’s why a lot of staff have suffered burnout; lots of staff have left the sector because there’s things we’ve had to do that just don’t fit into either our ethos or what our job role is.
What do we mean by care and what does the workforce look like?
Jane Lethbridge: One of the reasons why this care crisis has not been solved is because of the way that care is viewed. Care has been traditionally done by women in the home. Most unpaid carers are women. The skills and expertise needed to care are not valued within society. In contrast, acute medical care requires expertise that takes many years to acquire and is part of a high-status medical profession.
In 2021-22, the adult social care sector was estimated to contribute £51.5 billion (gross value added) per annum to the economy in England - an increase of 2% from 2020-21. However, in 2021-22 only 1.62 million jobs were filled of a potential total of 1.79 million social care jobs, resulting in 165,000 vacancies - an increase of 55,000 on the previous year. This reflects major recruitment and retention problems rather than a decrease in demand for care workers. There is a vacancy rate of 10.7%.
Brexit has also had a significant impact on the care sector by making it more difficult for workers from Europe to enter the UK. Since February 2022, although care work has been added to the shortage occupation list, only “adult senior care workers with professional training” are on this health and social care visa list. To be eligible, workers have to be paid £20,480 and have a licensed sponsor. This salary level is relatively high for care workers so that not all care vacancies will be covered by these new arrangements. Of the care workers entering the country using this route, 90% were from countries outside Europe. In 2022, 11,000 care workers entered from outside the UK.
How much are carers paid?
JL: The median hourly rate for social care work is £9.50 and many social care workers are paid less than this. In comparison, the major supermarkets, Asda, Tesco and Aldi, have recently increased their hourly rates to over £11.00.
Meanwhile, it is often the case that social care workers do not have permanent contracts, and instead find themselves on zero-hours contracts or doing limited part-time work. For private companies that provide the majority of care services, their success in winning contracts depends on reducing labour costs, hence the low pay for social care workers.
And there are millions of carers who are paid nothing at all.
The 2021 census estimated that there are 5.7 million unpaid carers in the UK and that 59% of unpaid carers are women. Carers UK estimates the total number could be higher at 10.6 million. Estimates of the value of this type of informal care range from £58 billion to £100 billion per year.
These people have to manage both unpaid caring and often paid work. But not all workplaces are supportive and don’t allow paid time off or flexible working. That means that taking on caring responsibilities often affects a carer’s finances. At the beginning of the pandemic, over half (58%) of unpaid carers from black, Asian and minority ethnic groups said they were worried about their finances, compared to 37% of white carers.
Why is social care always a lesser priority than the NHS?
JL: When the NHS was founded, other parts of the welfare state were also set up. The National Assistance Act (1948) meant that local authorities became responsible for providing services for “disabled, sick, aged and other persons” and for regulating homes and charities for such people. Local authorities improved welfare accommodation, community nursing services and developed preventive and social support services - for example, the home help services.
But, social care was never given the same resources and attention as the NHS.
In the 1980s, the planned closure of large mental hospitals was accompanied by campaigns for care in the community. This became the focus of campaigning by groups representing older people and people with disabilities.
Then, there came a fundamental change in 1990, when the NHS and Community Care Act required local authorities to commission services rather than provide them directly. So by 2010, almost all previously local authority-run services were privatised.
Although local authorities commission care services and pay for service users who have less than £23,250 savings, other service users have to contribute to the costs of care. In many cases, when people enter residential care, they may have to sell their homes.
What did privatisation and austerity do to care?
JL: The privatisation of care services changed the way in which care is assessed and costed so that it became a commodity to be bought and sold. As the care sector is a labour-intensive sector, the main source of profit is generated by reducing labour costs. Care was transformed into a series of tasks that didn’t take into account the empathetic and relationship-building skills that are a crucial part of the job.
The use of digital technology has also given the employer, or commissioner, more control over the worker by timing the delivery of care. Some visits can be as quick as 15 minutes. It is hard for a carer to provide quality care if they are on the clock.
And the quality of care also depends on workers being well paid, well trained, supported and able to work in a safe environment. The profit motive undermines the basis of high-quality care services.
Private sector care companies have attracted private equity investors because care services are seen as a growth sector in a country with an ageing population. However, private equity investors are interested in short term returns on their investment and often load care companies with debt. This has resulted in the financial collapse of care companies, such as Four Seasons in 2019.
Austerity policies introduced by the coalition government in 2010 and continued by subsequent Conservative governments introduced cuts to local authority spending. The National Audit Office estimated that government funding for local authorities fell by 49.1% between 2010-11 and 2017-18. Between 2010-11 and 2016-17, local authority spending on adult social care services was reduced by 3.3% in real terms.
In addition, there were more substantial reductions in other public services, such as housing, which impact on people requiring care.
How do other countries tackle this issue?
ACH: It may appear logical that spending on long-term care would take up a larger share of Gross Domestic Product (GDP) as the population ages. However, in practice in the last decade we have seen that this sector has not grown as would have been projected based on demographic change. The European Ageing Report published in 2012 estimated that, by 2025, on average public expenditure in long term care as a percentage of GDP in the European Union would reach 2.2%. In contrast, in 2021 the same report projected a lower amount, 1.8%. This is because in the context of austerity measures public long-term care expenditure has been cut in real terms in many countries, despite growing need.
In line with the UN’s Decade of Healthy Ageing, some countries are adopting a more pro-active approach towards preventing care dependency through public health initiatives and rehabilitation. For example Denmark, Japan and Singapore all have initiatives aimed at supporting and enabling people to retain their capacities for as long as possible, potentially reducing their need for care in the future.
In Denmark, for example, people who are discharged from hospital are entitled to a rehabilitation package before being assessed for social care. As well as this preventative approach, there is increasing awareness of the importance of strengthening home and community-based support, avoiding unnecessary admissions to care homes.
What would a National Care Service look like?
JL: We will all need care at some time in our lives in the same way that we all need the NHS. Yet, there is no National Care Service (NCS).
An NCS would provide care that is free, like the NHS, when people need it. For example, if an older person needs some help after coming out of hospital, their GP would contact the local neighbourhood care centre, where care workers would be based. There would be an agreement about what the older person needed – maybe daily help getting up and going to bed for a few weeks. There would not be a charge for this service, but the arrangement would be reviewed regularly.
A relationship would build up between the home care worker and the care patient, allowing the carer to become aware of any emerging problems or other support needs.
Support for unpaid carers would be an important element of the NCS. This could be done by providing care at specific times in the week, which could allow the unpaid carer to go out or go to work.
The NCS care worker would have a permanent contract, be well-paid, with good terms and conditions and regular training. They would be encouraged to spend time creating good relationships with their clients so they would no longer have to complete their visits within 15 minutes.
The many forms of care which are currently delivered by mainly private sector providers would be gradually taken over by the local authority care service.
Both the NHS and the social care sector have high numbers of vacancies. Because social care employment often acts as a stepping stone to NHS employment, a workforce plan for the NHS has to include a workforce plan for social care, otherwise increased recruitment to the NHS may result in worsening recruitment to the social care sector. Strengthening the links with NHS jobs would help to make care workers part of a health and social care profession.
Despite the issues caused by Brexit, migration is not a long-term solution for the workforce crisis. Recruiting care workers from countries in Africa and Asia, deprives these countries of their own health and social care workers.
The recruitment of young people into the social services sector is crucial to establishing a sustainable social care workforce. As many young people lack knowledge of social care services, several social services organisations in Europe have set up schemes which encourage young people to volunteer and gain experience of social services work. Care apprenticeships are another way of encouraging young people to work in the sector.
What is the economic and political case for a National Care Service?
ACH: Looking at international experiences on long-term care financing shows that unpaid care by family and others is the largest care resource. Of the total health and care costs for people with dementia in England, 42% was unpaid care. Unlike formal care, unpaid care is not valued as economic activity, but it does have a cost to those who provide it. There is also growing evidence of the negative health and financial impacts of having to provide care for long hours without formal care support.
While not everyone will need substantial amounts of care, there will be some people for whom the costs of care will be very large, potentially wiping out their entire income and savings. Public long-term care systems essentially insure the population against the risk of needing care.
Countries have adopted different approaches to covering this risk. At the very minimum, there is some support for people without family care or financial resources, with the charitable sector often playing a role, as the Orthodox church does in Greece, for example. There, the church provides a network of services (including care homes and day care centres) for older people, particularly those on a low income and who live alone.
Many countries have expanded their welfare states to cover the risk of needing care, at least partially. Countries often adopt a financing system that is consistent with the way they finance health care. For example the Netherlands, Japan, Germany, Israel, Luxembourg, South Korea, and some large cities in China introduced new social insurance systems, raising additional revenue earmarked for long-term care.
In Nordic countries, which have a tradition of funding public services through general taxation, the public system expanded the coverage of long-term care as part of the universal welfare system, with relatively small added payments on top of the general tax bill. In England, access to publicly-funded care is both means and needs tested, leaving a large share of the population outside the public system.
While many countries started building their formal care infrastructure by providing residential care for people with severe care needs, there is increasing awareness of the importance of developing a community-based care infrastructure that supports people living at home.
While for some people it may not be possible to live in their own homes due to having intense and complex care needs, it is important to rethink the more traditional approach to residential care. Larger care homes experienced disproportionately higher COVID-related mortality during the pandemic and research shows that small, modern and home-like care homes (such as the Green House model in the United States) had better outcomes.
Partly in response to the pandemic, the Spanish government is currently developing a de-institutionalisation strategy for their care system, following in the footsteps of Nordic countries previously, where care home residents have their own apartments with their own facilities and often direct access to the outside.
How can it be fixed?
JL: Seven reports published since 1999 have set out how social care could be funded and how much people would be expected to pay. The Sutherland report (1999) concluded that the most efficient way of providing care was through the pooling of risk by “services underwritten by general taxation, based on need rather than wealth”. It recommended that personal care should be free but living costs and housing would be met from people’s savings and income, with the means-test level raised to £60,000. The 1997-2003 Labour government rejected this proposal, which would have provided free personal care.
The Dilnot Report 2010-2011 recommended a lifetime cap of £35,000 for people aged over 65. Again, no action was taken by the 2010-15 coalition government.
Scotland has taken a different approach. The Scottish Parliament’s Health and Community Care Committee accepted that free personal care should be adopted on “the basis of assessed need”. The 2002 Community Care and Health (Scotland) Act 2002 was passed, and free care became available for people aged over 65 from July 2002.
A report by the Joseph Rowntree Foundation in 2007 found that the impact of making care free at the point of access in Scotland had resulted in increased demand for care, although this varied between local authorities. There was still widespread support for free care and people were still willing to pay more taxes to fund it.
ACH: Developing a system that ensures that people living with disabilities and losses of capacity have the same rights to health, family life and participation in society as everyone else, and that protects unpaid carers from excessive burdens while ensuring decent work for care staff requires investment.
As the population ages, more of us will live with losses of capacity and will need care. Concerns about fiscal sustainability have often been presented as a barrier to more generous care systems, and while it is an important consideration, decisions about the share of public spending that is allocated to different areas are political.
In countries with more generous public long-term care systems (Denmark, Netherlands, Sweden, Norway), public expenditure is around 3-4% of GDP, which is more than double the current share in the UK.
Even a doubling of spending on long-term care would still represent a relatively small share of a country’s economic production.
The provision of care for an ageing population is one of the biggest issues facing society today. The pandemic has raised public awareness of the need to strengthen and modernise the care systems in many countries. Some countries appear to have been better able to translate this public awareness into political will.
But the UK appears to be trapped in a vicious cycle of low expectations about the social care system. The result is a lack of political will to engage with the more fundamental reforms that are needed.
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