There have always been ways to tell when a crisis is coming. Miners used to take canaries into coal pits as an early warning of a lethal gas buildup – if the canary was singing, all was well. When the singing stopped, the miners knew they had minutes before the gas killed them, too.
In today’s health and social care system, the number of delayed transfers of care (DTOC) are an equivalent warning to the sector. Worryingly, this particular canary is currently lying prone at the bottom of the cage. According to figures published this month [pdf], there were 188,300 delayed days in August – the highest figure since monthly data collection on DTOCs began six years ago.
As social care leaders gather in Manchester for their annual conference, all of them are grappling with tough choices and hoping for good news in the autumn statement, which will be delivered by Philip Hammond on 23 November.
Last autumn I spent time visiting and speaking to NHS trust chief executives and social care leaders about transfers of care as part of the Right Place, Right Time commission [pdf] for NHS Providers. Even then, there was growing concern about the fragility and paucity of social care.
The sector has been hollowed out by chronic underfunding. Increasingly heroic efforts have kept services ticking over, and there are still amazing examples of great care. But as the Association of Directors of Adult Social Services (Adass) warned earlier this year in its annual budget survey report: “Financial risks are rapidly increasing ... the quality of care is compromised.”
Since Adass issued its warning in July there have been a succession of reports issuing stark warnings about the state of social care. The King’s Fund/Nuffield Trust report, Home Truths [pdf], concluded that councils were struggling to meet basic statutory duties.
It’s not just funding. It’s the workforce, too. Independent Age commissioned an analysis of a range of migration scenarios pre- and post-Brexit. It found that the workforce gap could grow to anything from an optimistic 750,000 workers to a pessimistic 1.1 million by 2037. The treasury thinks it has fixed the problem with the social care precept, a regressive tax that raises funding where it is needed least.
The Care Quality Commission (CQC) is also sounding the alarm. In its annual state of care report [pdf], the CQC issues its starkest warning yet. The “fragile” social care system is approaching a “tipping point”, it says. Far fewer people are being supported than those who actually need help.
Rather than a spectacular collapse of a large provider (which may still occur), it now seems that steady attrition of provision is becoming more likely. Providers are handing back contracts, selling up and exiting the market. Investors considering the returns on care sector investment are also walking away, choosing to finance up market provision for those who can pay. It is high time the government had a serious rethink of the type of housing with care they want to promote.
Often, policymakers tell us that integration between health and social care is the answer to these mounting pressures – how, they ask, could anyone be against integration?
But the evidence is sparse. It may be good for the service user and the family carer, but when it comes to stretching the money it is no panacea. Discussions about greater collaboration between health and social care are still missing out on an essential part of the jigsaw: housing.
More than half of all tenants living in general needs housing provided by housing associations are over 60. Housing associations should be key partners in creating accountable care organisations (ACOs) and networks. The danger is that ACOs will continue business as usual, just with a new wrapper.
An audit [pdf] of the work of National Housing Federation members with the NHS demonstrates that sustainability and transformation plans and the ACOs that may emerge from them would benefit by considering housing in their population health ambitions.
Population health also needs smart use of data to gain insight and inform action to prevent and postpone the need for more costly health and care interventions. On a recent visit to Liverpool, I was struck by the practical yet visionary approach local NHS digital leaders there are taking to linking analytics in areas from technology enabled care to digital health redesigning services.
Starved of funds, the shortage of social care is undermining the NHS and driving families to breaking point as they try to juggle caring responsibilities with work.
The autumn statement could be the moment the government recognises social care as being vital to our economy, and an opportunity to improve conditions for some of the lowest-paid in our society.
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