Some £3.5bn has been removed from local government spending on adult social care over the past three years, according to the Association of Directors of Adult Social Services. But as spending on social care goes down, does spending within the NHS go up to compensate?
Local authorities have struggled to balance the books following substantial cuts in grant support from central government – and social care is local government’s second largest cost (after education). Spending cuts on social care have been implemented by a variety of means – including cutting fees to care providers, but also by making the criteria for support much tougher and so reduce the number of people receiving assistance.
“Councils have needed to make 26% reductions over the last four years – 12% cash and 14% due to rising need,” explains David Pearson, president of ADASS. “They have done their best to protect adult social care, spending on which has risen from 30% to 35% of council expenditure over the past four years. “There have been many examples of creativity and innovation in the way that services have been delivered and in making savings through better advice and information; helping more people to remain independent through reablement; better support to carers; jointly commissioning or providing services with health as well as reducing services; and changing eligibility criteria and increasing charges. Despite the reductions, the proportion of delayed transfers of care attributable to social care has reduced over the last four years.”
Yet an ADASS survey of its members this summer found that 48% expect fewer residents will receive social care services in the future; 47% predict that over the next two years service users will be given smaller personal budgets to spend on their own care and support; and 55% believe that some care providers will hit financial difficulty. ADASS argues that more funding must be found if the social care system is to work properly and be safeguarded.
Significantly, exactly half of the ADASS members surveyed predict that the loss of some social care support will lead to greater pressures on the NHS. It is easy to see how social care cuts are likely to work through the system into the NHS. Hospital discharges will become more difficult if there are reductions in the support available to people when they leave hospital. And without help from home care assistants, elderly people living at home will be more at risk of accidents and malnutrition.
“The social care budgets of local authorities are under significant pressure and this is likely to get worse as the population ages and the percentage of older people with chronic diseases increases,” suggests Gillian Fawcett, head of public sector at ACCA. “We are sitting on a ‘ticking time bomb’ and need to have a radical rethink of how social and health care services can be delivered and funded to meet the needs of the most vulnerable in society.
“The biggest concern is that councils will not meet the needs of people wanting to remain in their own homes with social care support. Without such support it is more than likely to impact on the health budget, such as emergency health care services.”
The Nuffield Trust is in no doubt about the reality of cuts in local government social care budgets. Its report Social care for older people, published earlier this year, detailed the impacts. It found that annual spending on social care for the elderly between 2009/10 and 2012/13 had fallen from £10.6bn to £9.8bn, at a time of increased demand. As a result, nearly a quarter of a million fewer old people received publicly funded community services in 2012/13 than had done so three years earlier (a 26% reduction). The number of elderly people receiving meals delivered to their homes more than halved in the same period.
One impact on the NHS was absolutely clear, said the Nuffield Trust. Transfers of funding from the NHS to local authorities prevented social care services being hit even more drastically. Yet Nuffield concluded that a lack of data means it is not possible to accurately assess the impact of social care cuts on the health of the people affected, nor whether it caused the NHS to spend more on their treatment.
“You can certainly see the mechanisms by which reductions in social care would impact on the NHS,” says Mark Dayan of the Nuffield Trust. “But it is surprisingly difficult to prove because there is a lack of ‘tracking’ in the system. Making that direct link is very difficult.
“But we do at least know that at the end of people’s lives health and social care do tend to be substitutes for each other. But that doesn’t have to be local authority social care. The point is perhaps that the cuts in social care that we have seen – which have been pretty substantial – have to an extent been soaked-up by people paying privately and perhaps selling their homes; families looking after relatives; and maybe some of that falling on services provided by the NHS.”
It is clear that in many parts of the country, families are being forced to pick-up more of the bill for care services for elderly relatives. Tameside council in Greater Manchester has just been told by the Local Government Ombudsman that it was wrong to increase charges for residential care for an 80 old woman for whom funding arrangements had already been agreed.
The Ombudsman concluded that another 160 elderly people in Tameside – and their relatives – were wrongly required to make additional payments for care. Despite the finding, Tameside believes it did nothing wrong and was merely penalising care homes that did not meet its quality threshold. But underlying this is the reality that many relatives are increasingly required to make top-up payments where a council is making cuts.
“Our complainant was in a very difficult situation, he could not move his mother and risk her health deteriorating, and he could not afford to pay the extra money the council demanded,” said Local Government Ombudsman Dr Jane Martin.
Both the Government and the opposition Labour Party seem committed to much greater integration of healthcare and social care in the hope that this will lead to the two services becoming more synchronised. Labour’s shadow health secretary, Andy Burnham, has proposed moving social care out of local government and into the NHS. Conservative health secretary Jeremy Hunt has suggested the less revolutionary approach of having Clinical Commissioning Groups take joint responsibility with local government for social care.
But it seems unlikely that either approach will resolve the problems unless they also come with a significant injection of extra cash.