Baroness Cavendish’s independent report – commissioned in June 2020 by then Health Secretary Matt Hancock, and published last week – seeks to make sense of the post-COVID world of social care, and provides a series of recommendations for a joined-up health and care system which works for people in a meaningful sense.
The report limits its scope to those over the age of 65 – with the justification that lessons can be transferred across the full spectrum of social care in the UK. In reality, the split between social care spending on working age adults and those over 65 is almost equal (as per the King’s Fund research), and so it is crucial that younger adults – particularly the 70% of this demographic with learning disabilities – do not get left out of the sector-wide insights and decisions which affect their lives.
Nonetheless, for those within the scope of the report, the recommendations could have some impact in improving their experiences of care.
The report identifies that the planned integration of health and care must not be a de-facto term for the NHS ‘taking over’ social care. Baroness Cavendish is vocal in her criticism of the health service as it currently stands, positioning it as incohesive, overly bureaucratic and lacking in humanity. It is, she argues, therefore incompatible with the delivery of person-centred care.
To that end, she recommends that social care commissioning remains with Local Authorities but with more consistency of oversight, and not before a revolution occurs in the way data is held, used, and shared, between individuals and organisations. The report sets out recommendations to reform commissioning in a way that would achieve these aims and move commissioning away from procurement and ‘time on task’ approaches, and towards a focus on care outcomes.
To improve commissioning approaches, there is an urgent need to build trust between public sector commissioners, regulators and the NHS, and largely private sector providers. This lack of trust became critically apparent in the crisis of the pandemic, and, as a result, additional bureaucracy and cost was needed to try to bridge gaps between organisations and bodies which could otherwise join up to deliver better care outcomes.
In the midst of this systematic mistrust, finds the report, people who fund their own care are being overlooked. This group accounts for about 45% of care home residents and around a third of other social care users so is not insignificant – but with little data held on this group, people who are consumers in the care market lack important support and information to make the best choices for themselves and their families.
Changes to the provider market are therefore necessary, argues the report, in order to enhance transparency of cost for consumers and to increase stability. To do this, new sources of capital must be attracted, and there must be a shift towards helping people to stay in their own homes for longer as they age. The report reflects on a range of models in this area, but ultimately warns against a government-regulated private market, in favour of a drive for more transparency, and better oversight of care outcomes. In this regard, Baroness Cavendish positions herself against a so-called National Care Service, advocating instead for the on-going role of the private market in delivering care, so long as those receiving care benefit from positive outcomes.
With workforce shortages at the forefront of everyone’s minds across the care sector, the report recommends action is taken to change the perspective of the social care workforce as a ‘last resort to manage decline’ and instead focus on promoting the role of carers in building strong relationships between individuals, families, and neighbour networks. Building ‘one united workforce’ is critical, but the report makes an important distinction between a ‘united’ workforce and one single workforce shared between NHS and social care – again speaking to the importance of integration not resulting in domination by the NHS over care.
The report’s ultimate recommendation for the workforce is for a national care workforce strategy to sit alongside the NHS People Plan, delivering joined up training and professional development for health and care workers based on population health and care needs. The report poses the question of who would take ownership of such a strategy – suggesting Health Education England, or employers themselves.
Before that question can be answered, however, there is an urgent need to address the lack of parity between the health and care workforces – something which is evident in the report’s role mapping exercise between health and care roles. This exercise demonstrated that the care workforce is not ‘less skilled’ and that in fact there is significant overlap between the tasks and responsibilities of health and care workers, which is often unmatched in parity of supervision and reward. In practical terms, perhaps an eventual care workforce strategy should include recommended pay bands for different levels of care workers, aligned to the NHS pay bands, which would start the journey towards parity between similar roles.
The scope of the report is vast – but ultimately hinges on the idea that the conversation about social care too often focuses on money, and not often enough on care outcomes and person-centred care. Undoubtedly, the national media’s focus on older people selling their homes or using their life savings to pay for care has driven the current debate around reform of the sector to focus simply on protecting the assets of older people – rather than considering what funding is required to give older people the type of lifestyle they want, in the environment they want, irrespective of their declining health. Arguably, the Government’s somewhat arbitrary ‘cap and floor’ cost reform package seeks only to appease newspaper headline writers, rather than provide the estimated £7bn/year funding shortfall a well-function social care system requires.
Seeing the use of language such as ‘humanity before bureaucracy’ and talk of social prescribing, focus on prevention, and building relationships, is refreshing. However, for those at the forefront of care delivery, these are far from new concepts, and there are many across the sector who have been waiting for these ideas to translate into meaningful action and policy for some time. Whether or not this report will achieve that shift remains to be seen.
