After “the end of local government as we know it,” what next for social care?BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6696 (Published 14 December 2016) Cite this as: BMJ 2016;355:i6696
- Jon Glasby, professor of health and social care
Earlier this week government ministers met to consider rises in council tax to provide extra funding for adult social care in England.1 While extreme financial and service pressures have recently hit the headlines, they have been growing for some time. In 2012, the leader of Birmingham City Council (thought to be the largest local authority in Europe) described draconian cuts as the “end of local government as we know it.”2 The so called “Barnet graph of doom” also showed that children’s services and adult social care could consume all of future council budgets, with nothing left for services such as refuse collection, libraries, parks, leisure centres, and roads.3 Since then, the cuts have continued relentlessly and the 2015 Association of Directors of Adult Social Services budget survey concluded that:
There have been 5 years of funding reductions totalling £4.6 billion [€5.5bn; $5.9bn] and representing 31% of real terms net budgets. This year, adult social care budgets will reduce by a further £0.5 billion in cash terms. Taking the growth in numbers of older and disabled people into account, this means that an additional £1.1 billion would be needed to provide the same level of service as last year.
There are more than 400,000 fewer people receiving social care services since 2009-10 and of those who are still supported, a significant number will get less care ... Only 7% of directors are fully confident that planned savings can be met in 2016-17 and 5% in 2017/18.4
The National Audit Office expressed similar concerns in 2014:
Providing adequate adult social care poses a significant public service challenge and there are no easy answers. People are living longer and some have long-term and complex health conditions … Need for care is rising while public spending is falling, and there is unmet need. Departments do not know if we are approaching the limits of the capacity of the system to continue to absorb these pressures.5
Despite repeated calls for the government to prioritise social care spending,6 there was a “deafening” silence in November’s Autumn statement.7 Although the government had previously allowed councils to charge an additional 2% precept on council tax to fund adult social care responsibilities, this was a drop in the ocean. In 2016-17, this power was used by 95% of councils and raised just £382m; Richard Humphries, assistant policy director at the King’s Fund think tank, warns that this is less than 3% of what councils plan to spend on adult social care and won’t even cover the £612m estimated cost of instituting the national living wage this year.8 To make matters worse, those areas with the highest needs are often the least able to pay extra local taxes, and so current rumours of a further increase in the precept—though tempting in a crisis— would only deepen existing inequalities.
Taking a step back, part of the problem lies in the fact that social care (for both children and adults) is poorly understood and suffers from substantial stigma. Even now, most of the debate is being framed in terms of older people and the knock-on effect on hospital services rather than in terms of the terrible effect that the cuts have on the lives of children and families, disabled people, people with learning disabilities, people with mental health problems, and older people alike.
Over decades, we have failed to find a permanent settlement for social care and we are now seeing the consequences of our neglect. This is arguably a failure of political leadership, a failure of social care to talk with a unified voice, and a failure of members of the public to take an interest until they need the services in a crisis and realise quite how bad the situation is. New Labour tried to launch a “big care debate” to find a lasting solution, but this quickly became too difficult to achieve politically (with unpopular decisions needing to be taken in the here and now that would benefit only future governments or generations). As with previous attempts, it was quietly kicked into the long grass.9
In the short term emergency funding is essential. This could be achieved through a highly problematic increase in council tax or by bringing forward new money promised in the government’s Better Care Fund.8 However, these are not long term solutions.
Nor should we expect the current emphasis on integrated care to free up substantial sums. While joint working can lead to better patient experience, it remains to be seen whether it can also save money—and the complexities of delivering this agenda are such that the received wisdom is that “integration costs before it pays.”10 11 Ultimately, the current implications of this crisis for the NHS are only the tip of the iceberg, and nothing short of a national debate, a cross-party consensus on the future of social care, and a new settlement will suffice.
Follow Jon Glasby on Twitter @JonGlasby
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare
Provenance and peer review: Commissioned; not externally peer reviewed.