The coronavirus crisis has forced us to confront two realities. Firstly, that we are all vulnerable. Some of us may be blessed with more resilience than others, but we are all exposed in some way and in consequence we all have a need for a functioning health and social care support system. Secondly, that the UK doesn’t have a functioning social care system — indeed, it is a system that is making it more likely that those most at risk will be killed by Covid-19.
Data from across the world shows that deaths from Covid-19 mainly occur among older people, particularly those over 80. Figures released last week by the Office for National Statistics showed that 16,443 people had died in UK care homes – almost one third of the 52,161 total deaths recorded in the country by 5 June. At the same time, in the UK, almost 1.5 million disabled, elderly, and chronically ill people have been self-isolating indoors for more than twelve weeks.
Many were essentially in solitary confinement and, as a result, suffering enormous mental anguish, not least those with depression or incipient or actual dementia. Residents in care homes were trapped in their rooms, with no visits from relatives — even when gravely ill or dying — and minimal interactions with staff. The decision to exclude relatives has meant that care homes have become closed institutions, increasing the risk of neglect, or even abuse.
Our social care workforce is generally poorly paid, with poor terms of service and high staff turnover. A recent study from the Resolution Foundation found that care workers were four times more likely to be on zero-hour contracts and that 58 per cent were paid less than the Living Wage. Many will have a heavy daily schedule — providing brief but intimate care for a large number of people. They’ve also been shown to be last in the queue for personal protective equipment (PPE) and Covid-19 testing.
The people for whom they care are probably those most at risk from the virus and it is quite probable that many care workers will be ‘high risk’ themselves. No less troubling is the government’s announcement that people in nursing homes may not get the hospital care they need and, as the BBC has reported, relatives are being rushed into signing ‘do not resuscitate’ forms.
The appalling state of social care funding in the UK means that those at greatest risk — those living in social care and nursing homes — have been least able to effectively ‘self-isolate’ and most likely to contract the virus, and in consequence to die. We do not know the full extent of the Covid-19 related deaths of those within the social care system — but the strong likelihood is that it is severe.
In Scotland, by mid-April, we knew that half of all care homes had Covid-19 infections, with thirteen deaths reported in one home in a week and at least one in four of all related deaths occurring in nursing homes. The industry body Care England estimated that the death toll in care homes in England was nearer 7,500 and rising.
Even for those receiving social care who do not succumb to the virus, there is every risk that they will suffer disproportionately from the state of emergency in the health service. The unintended consequence of the clearance of hospital wards in anticipation of a flood of corona cases, the reduction in GP services, podiatry, speech therapy, mental health services, and physiotherapy services will include considerable anxiety, increased risks of impairment, as well as delayed diagnosis and treatment. For those with cardiac problems, strokes, or who are awaiting cancer diagnosis and treatment, the prospects are likely to be even more serious.
Privatised, Fragmented, Underfunded
Social services in the UK are among the most privatised and fragmented in the western world. They have been underfunded for decades. Between 2010–11 and 2017–18 local authority spending on social care fell by 49 per cent in real terms, reducing spending from £16.1 billion in 2010 to £14.8 billion in 2016–17. Reduced funding has been accompanied by privatisation and the shifting of responsibility for funding to individuals, as well as the tightening of NHS and local authority eligibility criteria. Often, there have been long delays in assessing eligibility, and inconsistent and inequitable application of criteria.
According to the Competition and Markets Authority (CMA) in 2016 the care homes sector was worth around £15.9 billion a year in the UK, with around 410,000 residents and 5,500 different providers operating 11,300 care homes for older people. For-profit providers own 83% of care home beds with a further 13% provided by the voluntary sector. In addition, sheltered housing and warden-controlled homes are important alternatives to residential care, but data on these are not collected.
Although £48 billion is flowing into this sector from the state and individuals every year in the UK, the industry expects an 11 per cent return on capital invested in the residential care sector. From US data, we can see that for-profit companies generally have the lowest staffing and poorest quality as they seek to maximise profits for investors. Care services in England employ roughly 1.6 million care staff of which 78 per cent are employed by the independent sector.
The sector was 120,000 workers short before Covid-19 struck, resulting in inadequate care, while the use of agency staff moving from one home to another increases the risk of disease transmission. Staff on zero-hour contracts do not receive sick pay, and often go to work sick. Despite this, the high risks to staff, as well as the high mortality associated with Covid-19 among frail older adults, social care has been a low priority for personal protective equipment.
The recent emergency legislation in the UK has severely curtailed the legal rights to social care services of elderly, ill, and people with disabilities living at home and in residential settings. In condemning this action the respected Disability Law Service pointed out that this was the section of the population most at risk of serious harm from Covid-19 and that a rational response to the emergency would have been to ‘radically redress the care and support deficits of the past decade, rather than take the action that is mandated’ by the Coronavirus Act.
The DLS concluded that the action was contrary to international law — constituting ‘regressive’ social care legislation targeting those least able to cope — and made no strategic sense. Downgrading service provision for the most vulnerable and lack of access to essential social care and other vital services such as speech therapy, physiotherapy, mental health therapy and routine NHS services will simply lead to more health crises, more hospital admissions, and more essential workers, such as NHS staff, having to take time off work to care for family members. It will also lead to more avoidable deaths.
In Scotland, 14% of the NHS workforce were off work as of April, with around 41% of those absences related to coronavirus, contributing to a major shortage of staff in the NHS and probably higher in social care. The extra capacity available to health services through flexible redeployment of staff is simply unavailable in the social care sector despite government advice that ‘Care home providers are advised to work with local authorities to establish plans for mutual aid, including sharing of the workforce between providers, with local primary and community health services providers, and with deployment of volunteers where that is safe to do so.’
Integrate Health and Social Care
The current emergency has exposed once again the pressing need for a universal integrated health and social care service. It has highlighted the failure of successive governments to get to grips with our failed system. What is required is a radical plan to bring services and staff back under government control in a national, planned and publicly accountable system so that high quality care is delivered by a trained and properly equipped workforce with decent terms and conditions of service.
The impact of Covid-19 provides the most compelling case possible for a national care service free at the point of delivery with all the elements of sheltered housing, community, and home support and residential care integrated. It would require legislation but (as with the Beveridge plan eighty-five years ago) many of the private providers funded by the state are in significant financial difficulty and the net cost of bringing these directly under local authority control is likely to be small.
Of course, the costs of running a national care system that mirrored the principles of the NHS would be significant, but two important factors must be appreciated. Firstly, that we are already paying for social care in the UK. For those not eligible for state-funded care there is no way of knowing what their costs will be: no way of off-setting the risk. Some will use up their entire assets in paying for it and some, such as those who do not require long-term care home support, will avoid paying altogether.
A national care system would be that ‘risk off-setting’ system that will ensure that the costs of care are distributed equitably, just as the NHS does for the costs of healthcare. It would also recognise the needs of the 5.8 million unpaid, informal carers, that make up around 10 per cent of people in England.
Secondly, according to a 2019 Institute of Public Policy Research paper Social Care: Free at the Point of Need, the cost would be of the order of 1 per cent of total government expenditure. This would not only do away with the debt and tax leverage and offshoring that characterises the current private social care system but it would provide secure, properly equipped, and remunerated employment for those who perform this vital work. In doing so it would go a long way to ensuring that we have a resilient and well-resourced system that not only frees up NHS resources for acute care but is also able to cope with the next epidemic.
Without radical action to bring about a universal health and social care system in the UK, it is obvious what will happen when Covid-20 arrives. The fragmented system of many thousands of providers will lack adequate PPE; will lack the staff to support those who do not need hospital admission; will lack the resources to implement comprehensive contact tracing and testing of suspected cases; will lack the ability to coordinate the temporary relocation of care home residents to safe, infection free accommodation allowing visitors; and will lack the resources to provide Covid-20-only facilities.
A national health and social care system would mandate the collection of vital data quantifying the impact of Covid-19 on the social care sector — data on the number of cases and deaths by age, gender, ethnicity (minority groups are over-represented among deaths and cases), and care setting, stratified by local authority area, ward, and GP practice. An integrated system would also allow detailed monitoring of staffing levels, sickness levels, the use of agency staff, and hospitalisation rates for staff, residents, and other vulnerable groups. Accurate, timely data is the key to controlling a pandemic.
Covid-19 has demonstrated just how costly it is to fail to properly fund health and social care. The billions now being pumped into the NHS are but a small fraction of the sums that are also being signed off to shore up the UK economy.
The vast majority of the people who die as a result of Covid-19 will be people failed not by the NHS but by social care — elderly, chronically ill, and people with disabilities. If this government is serious in its commitment to ‘never again’ allow a disaster similar to Covid-19, it needs a plan to transform our scandalous social care system: a system that fails those in need, lets down paid and unpaid carers, and shames the UK.