The problems of social care in English nursing and residential homes for older people and the role of state regulation

ABSTRACT

The problems facing English care homes for older people have largely been defined in terms of funding. This paper starts from the position that it is vitally important also to address the big issue of the social care system, especially the changing nature of private provision since the introduction of a quasi-market almost three decades ago, such that large corporations have become increasingly dominant. The paper focuses on the implications of a fragmented, for-profit system of provision for financial sustainability and care quality, particularly in terms of workforce issues. It argues that heavy reliance on regulation via the market and operating through competition and choice is misplaced and that state regulation can play a crucial part in securing improvement in these fields. It concludes that the Government’s recent (2021) proposals, which are mainly confined to funding and designed to prop up the current system, are unlikely to provide the ‘long-term fix’ that social care needs.

KEYWORDS:

• Care homes for older people
• English social care system
• changing nature of privatisation
• problem of sustainability
• problem of quality
• problems of the workforce

Disclosure statement

No potential conflict of interest was reported by the author

Notes

1. Keeping up with current debates and interventions is a challenging task, but there are many commentaries by journalists and think tanks that provide an introduction, e.g. Panorama, BBC1. Crisis in care: follow the money. 6 December 2021; and IPPR, 2021 State of Care Conference. London, 8 December 2021.

2. Recently and notably by Sir David Behan, former Chief Executive of the Care Quality Commission (the regulator for health and social care) and now the Non-Executive Chair of HC-One, one of the five largest corporate providers of social care. He told the Public Accounts Committee that the system needed more money, but that the money needed to go into (an unspecified) ‘reformed system’ (HoC Committee of Public Accounts 2018, Q.101).

3. The issue of ‘integration’ between health care and social care is not addressed in this paper, but see Lewis et al. (2021) for a rather critical assessment of the national pilot programmes, and Exworthy et al. (2017), who also found that the contribution of integrated care to improved outcomes remained ‘unclear’. Successful integration is hard to achieve in the absence of wider social care reform in respect of access and funding. However, it would not necessarily be desirable for example, to merge training for health and social care workers (HoC Health and Social Care Committee 2020), or to make social care the handmaiden of the NHS (as happened in 2020 with the Covid-19 pandemic, when the main consideration of the NHS was how to achieve rapid discharge from hospital, without due consideration of the effects on care homes (Lewis 2020)).

4. In a quasi-market, typically the state continues to finance the service in whole or in part (as in the case of social care) and to purchase care, while provision is contracted out to a mix of independent sector (private and third sector) organisations. The aims of such a system are, in the main, to increase competition and hence efficiency and choice. Such a market is also intended to maintain equity and stability and enhance quality (Le Grand and Bartlett, 1993).

5. In her study of domiciliary care workers, Hayes (2017) has argued that the marketisation of social care has reduced caregiving to ‘care for hire’ and advanced the deregulation of labour.

6. However, a recent YouGov poll (18 November 2021) showed that 72% of those asked thought that care was skilled labour.

7. Braithwaite et al. (2007) also looked at Australia, which at the time of their research had more in common with the US than England.

8. Grant Thornton (2018) has suggested that private providers should consider differential pricing, e.g. for better accommodation.

9. Hayes (2017) has addressed this issue for domiciliary care workers.