Public debates on the future of adult social care seem stuck. Coverage of institutional failings cause shock and there is acceptance that the sector faces a systemic crisis, but options for solving these problems are few and far between. The Conservative Government talks about the need for good quality care whilst loading severe cuts onto the sector. Our media eagerly cover cases of care home abuse, but rarely ask what lessons can be learnt from clear patterns of behaviour.
Fear and fatalism stalk the debate on the future of care. Social isolation, a lack of quality, and costly intergenerational wealth transfers are expected to characterise our collective response in the coming years. The cap on the cost of care has been postponed from 2016 to 2020. Even the regulator, the Care Quality Commission, recognises the inadequacies of this policy debate, declaring recently that there was ‘no widely shared vision for how the sector should change and adapt’ to face future challenges.
Where consensus exists it is rightly concerned with reform of public organisations. To halt the spiralling cost of the NHS, care services should be designed to reduce the need for elderly and disabled citizens to be admitted to hospital. This will be achieved by integration of health and social care services, giving clinicians, frontline staff and patients the opportunity to shape services in a more co-ordinated way.
While this is not only slow and difficult work (see UnitingCare in Cambridgeshire), integration does not speak to the experience of individuals receiving and providing care. Reforming administrative structures is unlikely to change frontline behaviour, and with notable exceptions (Plymouth Council’s programme of integration being one of them) the Government’s Sustainability and Transformation Plan will be citizen free zones.
And even seasoned observers are cautious that integration will stave off a funding crisis in adult social care before 2020. The Kings Fund argue that even if all Council’s add the 2% optional social care levy allowed by Osborne every year for the next four years, there would still be funding shortfall of £2.8bn to £3.5bn by 2020.
The crisis facing the sector has created a distance between policymaking and the latest research insights. Ask policymakers how health and social integration might tackle loneliness in old age, or about the relationship between commissioning procedures and social connectivity, and one is met with silence.
Public debate has instead ossified around the twin dilemmas of a funding gap and an aging population. These are both critically important for the future of care, particularly in regard to capital intensive care homes, but can cause discussion of what good care will look like in the future to be neglected. This is particularly surprising given the emphasis on wellbeing in the Social Care Act 2014.
What does the research tell us about wellbeing, and how can these insights inform policymaking in adult social care? As would be expected, a large body of work demonstrates the positive relationship between the size, density and variety of social networks and individual wellbeing. A recent analysis in 2016 used a representative sample of 7,000 people from Australia, Canada, Germany, Norway, UK and the US to show that social relationships outweighed both health and income as factors influencing individual wellbeing.
And from epidemiology we learn that, in an example of circular causation, wellbeing is one the main determinants of individual health outcomes. So social connectivity leads to heightened individual wellbeing, which produces improved health outcomes, which in turn is a contributing factor in wellbeing.
Studies into the relationship between social capital and health regularly find that geography matters. The quality of social capital embedded within a locality through communal institutions and associations, as well as the networks held by an individual, are shown to positively affect individual health outcomes.
These insights indicate that policy initiatives that seek to grow the social networks and associations that contribute to wellbeing could help to achieve the intentions of the Social Care Act 2014 and reduce future health costs.
Such initiatives would start with a review of commissioning procedures. Large scale care providers, who offer a standardised service at scale, have a competitive advantage over smaller, place-based, non-profit providers with diverse forms of ownership and governance. When cost is the primary factor in commissioning, providers who build services around the quality and stability of the relationship between care worker and recipient lose out.
Achieving improved care by improving wellbeing faces an evidence paradox. Stringent budgets mean commissioning authorities are unwilling to invest in measures to boast wellbeing because they lack clear evidence it will save money. And yet without any attempt to invest in wellbeing, it is impossible to prove it works.
All this points to a care system built on co-operative values and principles. Whatever legal and administrative structures that are built in the coming years, they will work best through co-operative methods of working – giving clinicians, frontline staff and patients the opportunity to shape services in a more coordinated way.