Speaker: Dr Tania Burchardt, The London School of Economics Adult Social Care in England: Policy, Spending and Outcomes The GTC CARE INITIATIVE ‘Conversations on Care’ Green Templeton College The GTC CARE INITIATIVE Developing a broader understanding of social care and health care Next ‘Conversation on Care’ takes place on Monday 23 November 2015: Assets-based approaches to Adult Social Care – Developing a new Public Service Offer Professor Jon Glasby, The Health Services Management Centre

Adult Social Care in England: Policy, Spending and Outcomes Tania Burchardt, Polina Obolenskaya and Polly Vizard Centre for Analysis of Social Exclusion London School of Economics

Outline Coalition government’s inheritance Goals and policies Resources Outputs Outcomes Challenges for the current government

The Coalition inherited a system already under pressure Increasing life expectancy Increasing numbers of physically and cognitively impaired young people surviving into adulthood Multiple boundaries in financing and provision of social care: NHS and local authorities universal, means-tested and needs-tested support individuals, families and the state residential and community care; direct payments public, not-for-profit and private providers Emerging concerns over care quality

Goals and policies “Wherever possible, we want people to call the shots over the decisions that affect their lives” “completely recast the relationship between people and the state: citizens empowered; individual opportunity extended; communities coming together to make lives better” “a much stronger society: one where those who can, do; and those who cannot, we always help”... and cutting the deficit!

Policies Future funding Commission on Funding of Care and Support (Dilnot Commission), Significant relaxation of capital means test for residential care (announced in March 2013 budget – now postponed) Lifetime cap on care costs (Care Act 2014, following Dilnot – now postponed) Eligibility criteria New national criteria for social care eligibility based on levels of need (came into force April 2015) Integration of health and social care Health and Well-Being Boards (Health and Social Care Act 2012) More pooling of existing NHS and social care resources (Care Act 2014; Better Care Fund) Support for carers Extension of statutory rights of carers to support from social services (Care Act 2014) Changes to right to request flexible working (July 2014) Regulation, monitoring and inspection Stronger statutory basis for Adult Safeguarding Boards (Care Act 2014) Local authorities responsible for continuity of care (Care Act 2014) Adult Social Care Outcomes Framework (from 2011) New inspection regime by Care Quality Commission (from 2013)

Resources Total local government funding in England fell by 40 per cent from 2009/10 to 2014/15 Total local government spending on adult social care fell by 10.3 per cent in real terms Total spending on adult social care including NHS joint arrangements and user charges (‘gross total cost’) fell by 7.4 per cent Spending on older people fell faster... despite a 10 per cent increase in the number of people aged 65 or over, and a 9 per cent increase in the number of people aged 85 or over

Resources did not match population growth

Real terms growth in observed and demand-adjusted spending (whole population, and aged 65 plus), England, 2005/06 to 2012/13

Outputs

Less care was provided Number of people receiving community-based services each year, by age Coalition Labour

Falling numbers of community service users % change 000s of clients in 2013/14 Age /06 to 2009/ /10 to 2013/14 Physical disability Mental health Learning disability Substance misuse Other vulnerable people Age 65 plus Physical disability Mental health Learning disability Substance misuse Other vulnerable people

Falling numbers of community service users % change Age /06 to 2009/ /10 to 2013/14 Physical disability Mental health Learning disability Substance misuse Other vulnerable people Age 65 plus Physical disability Mental health Learning disability Substance misuse Other vulnerable people

Falling numbers of community service users % change Age /06 to 2009/ /10 to 2013/14 Physical disability Mental health Learning disability Substance misuse Other vulnerable people Age 65 plus Physical disability Mental health Learning disability Substance misuse Other vulnerable people

...particularly in mental health % change Age /06 to 2009/ /10 to 2013/14 Physical disability Mental health Learning disability Substance misuse Other vulnerable people Age 65 plus Physical disability Mental health Learning disability Substance misuse Other vulnerable people

...and in substance misuse % change Age /06 to 2009/ /10 to 2013/14 Physical disability Mental health Learning disability Substance misuse Other vulnerable people Age 65 plus Physical disability Mental health Learning disability Substance misuse Other vulnerable people

Distribution of clients of community-based services by number of hours received per week, England, 2008/09 to 2013/14

Outcomes

ASCOF Domain 1: quality of life Domain 2: delaying and reducing the need for care Domain 3: experience of care and support Domain 4: safeguarding vulnerable adults

ASCOF Domain 1: quality of life Domain 2: delaying and reducing the need for care some improvements mid-period, now worsening again Domain 3: experience of care and support Domain 4: safeguarding vulnerable adults

Domain 4: safeguarding Adult social care users survey: improving (66% feel safe in 2013/14 compared to 62% in 2010/11) BUT YearAlertsReferrals Substantiated or partially substantiated (as % of completed investigations) 2010/11 92,865 95,06530,365 (41%) 2011/12133,395106,16534,670 (41%) 2012/13172,130107,65037,410 (43%) 2013/14n/a 104,050 individuals 43%

Domains 1 and 3: Service users, carers (and ex-users?) Quality of life and satisfaction with services of service users has improved (7 indicators out of 11) Quality of life and satisfaction with services of carers has deteriorated (4 indicators out of 5) Quality of life and satisfaction with services of people who are no longer eligible to receive services ???

Number of unpaid carers, by age group, UK, 2002/3 to 2013/14 (Source: FRS) All Wkg age Pens Child

Population aged 50 and over reporting to be informal carers, around 2007, OECD

Unmet need for care, by age group and number of difficulties, 2007/08 to 2011/12, UK (source: FRS)

1.Effective integration of health and social care Greater Manchester Combined Authority 2.Tackling high prevalence of poor standards of care and abuse More emphasis on prevention (learning lessons from child protection?) Creating conditions that enable ‘relationships of care’ to flourish (difficult in 15 minutes!) 3.Investing in the social care workforce High turnover identified as a risk factor by CQC Majority of domiciliary care workers are on zero-hour contracts Paying for significant increases in minimum wage Challenges for the current government

4.Addressing unmet need and relieving pressure on unpaid carers Shortfall in care expenditure was already £1.5 billion by 2012/13 Dilnot reforms postponed Rise in number of unpaid carers and intensity of caring is not sustainable 5.Reconciling further cuts and continued demographic pressure Local authorities have been successful in affording some protection to social care but LGA warns further cuts cannot be absorbed without risk to “basic services for vulnerable people” Challenges for the new government

More need, less money Projections of total local authority funding and population aged 75 or over, England, 2010 to 2019 Sources: ONS and LGA

The Coalition’s record on adult social care: policy, spending and outcomes SPCC working paper 17 Tania Burchardt, Polina Obolenskaya and Polly Vizard, LSE Forthcoming April 2016 in Lupton, Hills, Burchardt, Stewart and Vizard (eds) Social Policy in a Cold Climate, Policy Press.