Britain - Elderly Social care in England: a gruesome tale

spring 2022

It took the catastrophic effects of the Covid pandemic on Britain's elderly population to bring the already near-collapsing state of adult social care to public attention.

    The arrival of the coronavirus turned what had been a slow but sure attrition in this neglected, largely unregulated, privatised-for-profit sector, into sudden and desperate crisis. In the first 4 months of the pandemic, over 20,000 elderly care home residents in Britain died from Covid-19. Given the lack of available testing at the time, it is likely that this is an underestimation. In the space of 12 months, between 16 March 2020 and 30 April 2021, there were 41,675 recorded deaths of the elderly in residential care over a quarter of all Covid deaths so far registered in England.

    The immediate cause was the frantic discharging from NHS hospitals of thousands of elderly patients into care homes at the start of the pandemic, in order to free up NHS beds; the government's policy-watchword at the time being "Protect the NHS", first and foremost, and at all costs... So, between 17 March and 15 April 2020, as many as 25,000 patients were discharged from NHS hospitals in England and Wales, without prior Covid-19 testing and without ensuring that they could be isolated from other residents.

    This policy has only now on 27 April 2022 been "officially" condemned by a High Court ruling. Two women whose fathers both died of Covid-19 in care homes in 2020, took Public Health England, NHS England and the Department of Health and Social Care (DHSC) to court, accusing these public bodies of having failed to protect elderly residents. Back in 2020, then Health Secretary Matt Hancock had claimed that a "protective ring" had been thrown around the most vulnerable... This was about as as true as Johnson's hair-raising promise at the time, that his government "was putting its arms around every single worker".

    Clearly what happened was quite the opposite. But despite the High Court finding that the discharging of patients into care homes was "illegal", all it did was to give the DHSC a moralistic ticking off. There were no penalties attached to the lethal "mistakes" it made. The damages claim by the plaintiffs against the Department was dismissed. As it happens, the Health Secretary of the first Covid wave, Matt Hancock, has since resigned not because his policies added to the Covid death toll, but because he was caught kissing a co-worker in his office... As always, incidents which might expose fundamental flaws in the system, are conveniently hidden behind MPs' trivial pursuits, inflated into personal scandals.

    But it was not only the panic over Covid and the government's wholly inadequate policy in face of it, which set the stage for the lethal contagion which took place in British care homes. The care of the elderly and here one needs to distinguish the care of the middle and upper class elderly from the care of the working class and poor elderly has always been relegated to the very lowest priority in this capitalist, money-first society. And it was the poor conditions, understaffing and lack of adequately trained and motivated professionals, not to mention the utter lack of protective equipment and test-kits, in this whole miserably-resourced sector, which undoubtedly contributed to the rapid spread of the virus and the many deaths it caused. 

    And by the way, a high care home death toll due to Covid (over and above the fact that it affects the elderly more severely) was seen, not just in Britain, but in most of the EU, and especially in that bastion of private profiteering, the USA. Because everywhere (mainly rich countries, where the better-off can pay), the commercialisation of care services has degraded the level of care.

    In this respect, it is worth quoting the House of Commons Select Committee of October 2021, which admitted that while "The UK was not alone in suffering significant loss of life in care homes (...) the tragic scale of loss was among the worst in Europe and could have been mitigated".

    In this article we will look briefly at the background to this "worst" scenario.

Never free at the point of use

While the provision of elderly social care has never been even close to what was required, the problem which was most pressing in recent years was the personal funding of long term residential care: even the relatively well-off elderly were being forced to sell their homes and mobilise all their assets in order to pay for it. So when Boris Johnson got himself into government at the end of 2019, in his first speech as prime minister, he promised to "fix the crisis in social care once and for all". Perhaps, like everything else he says, this was not meant to be taken seriously. But nevertheless it is an indication of how bad things had got.

    So what had led to this state of affairs? In one word, it is "privatisation". But that is not the whole story, because social services and especially adult social care, unlike medical care, were never placed fully into the public domain when the welfare state was launched. The 1948 National Assistance Act at least formally established state-provided social care. It gave the instruction to local authorities " provide residential accommodation for persons who by reason of age, infirmity or any other circumstances are in need of care and attention which is not otherwise available to them". And while the NHS was to be free at the point of use, it was decided that social care could carry charges, and that it should be subject to means-testing. This meant that the care provided by local parishes (under the poor law!), charities, churches and family members which had been the only resource available before 1948, continued to act as back-up afterwards. What is more, services were administered by a whole range of uncoordinated government departments including health, education and the Home Office which resulted in patchy provision, delay, confusion.

    For instance throughout the 1950s, disputes occurred over whether the care of the "frail" elderly should be the responsibility of the NHS or local government. And already in the 1960s, that derogatory label, "bed blocker", was applied to the elderly infirm who needed NHS hospital care or a level of nursing care not available in the residential system.

    In fact since these frail elderly were or should have been the responsibility of both the NHS and the local authorities, neither took full responsibility; they both passed the buck. At the same time, government policy began to focus on supporting people to stay in their homes, rather than move to authority-provided residential accommodation, as a way to save the state money, but also due to public outcry over the poor conditions in these institutions.

    In 1965 the then Labour government set up a committee under Frederic Seebohm, with the task of setting up a more co-ordinated social services system providing joined-up care "holistic" as it was described (and hoped for) and the establishment of a unified social service within each major local authority. However the care of the elderly was still regarded as a somewhat separate category, even if the intention was to co-ordinate local authority services as far as possible with health services. At the time, 10-year plans were developed for hospital and community care services. But the reorganisation of the NHS, 6 years later in 1974, again disrupted this planning so no real reforms were implemented. But anyway the main issue was always funding and it was always being cut.

Careless in the community

The current organisation of social care is rooted in the Thatcher government's 1988 Griffiths’ reforms. And Griffiths was brutally honest in this respect: it focused on "the way in which public funds are used to support community care policy", i.e., it quite openly proposed how to cut spending on social care.

    It was now that the big cuts and privatisation drive began. "Care in the community" was dubbed "death in the community" by staff in the sector. In the grey area of care for the elderly infirm and especially the mentally infirm, the responsibility for this had fallen to the NHS and in particular the large psychiatric institutions. The policy of the Thatcher government was to shunt these patients (and indeed, they were "patients", requiring specialist medical and nursing care) into the community.

    Funding allocated to local authorities was accompanied by a central government requirement that as much as 85% of it should be spent on the "external" purchase of care services from the private sector.

    So, while 10 years before, in 1979, 64% of residential and nursing home beds were still provided by local authorities or the National Health Service, by 2012 the local authority share was just 6%!

    In the case of domiciliary care, 95% was directly provided by local authorities until as late as 1993, but by 2012 this was just 11%.

So what is now "provided"?

The short answer to the question "what is provided?" for adult social care is "profits". This sector was estimated to contribute £50.3 billion per year to the economy in England alone! And given the constantly ageing population it can only grow, constantly! In 2020-21 it comprised around 17,700 "organisations" running 39,000 care-providing institutions/homes. The independent "strategic workforce development and planning body for adult social care in England", SkillsforCare explains that "organisation" in this respect means "the large national employers, large charities, local authority adult social services departments and small independent care services. For example, a large company running multiple care homes would count once in these figures." The total workforce in the sector is around 1.67 million    more than in the NHS, which itself employs around 1.3 m! But the big difference is that the vast majority of these homes are privately run, mostly for profit. Only only a tiny number are still run by local authorities (or voluntary foundations like charities) which today employ only 6% of the total workforce.

    And what says it all about what exactly the elderly are provided with when they need to go into care, is the fact that most "organisations" (residential care homes) are described as "micro" (with 1-9 employees) in fact 37% have just 1-4 employees. Around 85% had fewer than 50 employees. Organisations that were large (with 250+ employees) make up just 2% of the total, even though they employed almost half (49%) of the total adult social care workforce in 2020/21. Apparently the largest 26 providers of social care, while accounting for 68% of the total revenue of the private sector, only provide around 28% of the beds.

    Significantly even the small establishments offer domiciliary care, with 51% of the total having taken over the provision of "care in the community" from local authorities sending home helps every day, etc... 

    What does all of this mean? Well, that a large proportion of care is still being offered by very small businessmen and women aiming to make a living with a good profit out of "caring". And that the reality of this is that they can only do so by squeezing the maximum out of their clients and providing the minimum of care to them. Across the whole sector the main means of keeping their costs down is to minimise the cost of their staff. 

... and at what cost to workers?

The exposure of the scandalous wages and conditions of care home workers during the Covid pandemic resulted in a panicked cover up of reality. But the fact that so many staff also caught Covid, and were not eligible for sick pay, caused such uproar because of the risks to vulnerable residents, that at least some of these establishments have subsequently cleaned up their act. So today the picture painted by SkillsforCare is likely to be somewhat air brushed, but nevertheless we can see that although their claim is that 89% of the adult social care workforce in England in 2020/21 was on permanent contracts, still, one quarter, 24% were on on zero-hours contracts (380,000 jobs) and for those providing domiciliary care the proportion on zero-hours contracts was almost half, at 42%! Despite the outcry at the use of such contracts in such a sensitive area of work, we are told by SkillsforCare that "The percentage of workers employed on zero-hours contracts between 2012/13 and 2020/21 has remained relatively stable, increasing by one percentage point over this period"! So no reduction then.

    All of this means that most workers only remain in this sector for as short a time as possible since it is not possible to live the wages paid, which are at best only £5/hr above the minimum wage for permanent workers. But in fact most obviously including those on zero-hours contracts are still paid the minimum. And out of that small "wage", those doing domiciliary visits must pay travel costs as well. Contrary to the pious and self-righteous assertions of care home bosses, therefore, this "job" is not considered to be a "career" which workers "love". How can it be, if you cannot live on the pay!

    With Brexit and the pandemic, a sector which has always operated with as few staff as possible (relative understaffing being the norm to save on costs) found it difficult to find enough workers to fill its jobs. By the end of the pandemic it was said that there was a deficit of as many as 100,000 workers!

    Of course, what had happened during the pandemic did not help. This workforce suffered some of the worst employee conditions throughout: staff had to turn up every day, regardless of risks. They had to cope with the requirements for protective equipment without actually being provided with it, due both to the Department of Health's incompetence and the parsimony of their employers, so they (like many NHS staff) improvised with bin bags etc. A total of 469 deaths from Covid among social care workers were registered in England and Wales between 9 March 9 and 28 December 2020, but in the first two months of the pandemic, 131 had already died. And yet at that point, testing for staff was still not even available. What is more a large proportion of social care staff come from a black and ethnic minority background, and this means they had twice (women) and three times (men) the risk of dying from Covid.

    It is also worth recalling that when it came to vaccination it is only in the social care sector where mandatory vaccination on peril of losing one's job ended up being enforced, which initially led to a minor exodus of staff, making the post-Covid worker shortage even worse.

Their hidden profits

The National Audit Office estimated in 2017, that the public spent £10.9 billion on privately-purchased social care. So the total "profit" made out of the system of over £1 billion a year is very likely to be a gross underestimate. In fact we are told that on average, care home company margins are as high as 15%!

    That is no surprise either: in 2021, the average weekly fee paid by local authorities for a care home place was £898, which has risen by 17% since 2015. However, for those who have to pay for their care themselves, fees are estimated to be 41% higher, which would mean a care home place costs £1266 a week on average!

    The Centre for Health and Public Interest (CHPI) reported that among the 18 largest "for-profit" providers of social care, £15 of every £100 received went to profit, rent payments, directors’ remuneration, or net interest paid out: a total of £560 million a year. As the CHPI explained, much of the debt loaded onto the care homes by the largest for-profit providers is owed to related companies that are often based offshore and at high rates of interest i.e. a form of hidden profit extraction which also avoids tax. The same is true of rent payments, which can be paid to related companies, often based off shore.

    Anyway, exact figures are hard to come by. Out of the 26 largest providers in Britain, 6 have an offshore owner in a tax haven; 18 split up their operating and property companies; and 12 purchase services or supplies from a related company. It's not easy to "follow the money"!

    Despite the evident profitability of the sector for the large operators, many of these privateers (especially post pandemic, of course) say that they cannot make enough money to remain in business.

    There have been some spectacular bankruptcies: for instance, in 2019, Four Seasons, the second biggest care home provider, with 17,000 residents, collapsed. Seven years previously it had been bought by a private equity firm, Terra Firma, in a £825m, debt-fuelled deal. As a result, at the time of its bankruptcy, Four Seasons was organised into 187 companies in nine subsidiary tiers, including 14 offshore, spread across at least six jurisdictions! In fact it's very likely that all of the "lost" money found its way through multiple hidden routes, back to its private investors. 

Unregulated "care" 

What is quite shocking is the fact that only two thirds of all adult social care establishments are actually regulated by the Care Quality Commission the body which is meant to monitor standards! In other words a third go completely unregulated! No wonder there are horror stories regularly screened on TV programmes like Panorama which reveal gross deficiencies in care, largely due to lack of staff and due to extremely poor living conditions for residents and poor working conditions for workers.

    It is not surprising that many among the elderly therefore choose not to go into care and to stay at home as long as possible. And that family members try to provide for them.

    The Office for National Statistics estimated that there are 6.5m adult and 180,000 child carers. This situation has long been "institutionalised" with the so-called Carers' Allowance (CA) which pays £69.70 a week. Despite the fact that it's a pittance, carers are only eligible for it if they spend 35 hours a week caring for somebody, i.e., if it is their full-time job! They are disqualified from CA if they earn more that £132/week, from another job. There are apparently 1.3 million CA recipients, and another 100,000 who are provided with some financial support through local authorities.

   Of course relatives are often obliged to intervene in order to provide care, mostly due to the utter inadequacy of what is on offer and the outright cuts in funding emanating from Central Government which have left LAs in the lurch. In 2020, despite the ageing population the number of adults receiving some kind of state-organised care, had fallen by half a million. Meanwhile, the requests for state support have have risen. In 2020, local authorities received 1.9 million such requests from new clients, but only 43% of these received any kind of service! Overall, social care expenditure in England has fallen in real terms by 9% since 2010. 

Johnson's "fix"

So how about the situation today? In fact local authorities (LAs)are still responsible for assessing people’s needs even if they hardly ever provide for them any more. If individuals are eligible for state support, the LAs must provide payment for their care. To be eligible, a person's assets should not be over £23,250. Even then, it is expected that any income received for instance a pension is used to pay towards care costs. If an elderly person owns a home, its value is added to his or her assets, which means that most home owners are not (at least initially!) eligible for state support. If they need residential care, they have to fund it themselves and once all their savings are used up, they are obliged to sell their homes to carry on affording it. Then, when they have used up all their resources and are down to their last £23,250, they can apply for local authority support...

    Unsurprisingly this system has been controversial from the outset, and not only because it prevented parents who needed long-term residential care from leaving their houses to the children. Of course, it could have been seen by some as a kind of "levelling down" of the better off, to the same level as those who were never able to own a home. But home ownership is common among the working class. Besides, it leaves the elderly struggling with the complexities of managing financial transactions in a timely fashion, trying to find a cheaper residential home, etc... Another big problem is the differing needs of each half of a couple: if they shared their home, but only one of them needs in-patient residential care, and the home must be sold, what happens to the other one...? Etc., etc...

    Back in 1997, Tony Blair just like Johnson today promised to fix things. He said he didn't want children to grow up "in a country where the only way pensioners can get long-term care is by selling their home". Since then, there have been a series of government reports on social care reform: two green papers, four white papers, and various consultations, as well as five independent commissions. The latest is the "Health and Care Bill 2021" from Johnson's Cabinet...

    What is it about? In fact part of it focuses on care home costs. The background to this is the 2010 Dilnot Commission which recommended applying a limit, or "cap". But the real problem was that no extra government funding was forthcoming.

    Nevertheless or maybe because no extra government spending is involved Johnson's government is now revisiting Dilnot with his amendment to his Bill. (Although the bill talks also about "integrated care" joining up NHS and social care services in reality it paves the way for further private sector outsourcing and, while pretending to get rid of bureaucracy. it proposes more cuts.

    Anyway, by October 2023 a cap is meant to be introduced on self-funding for residential care: once someone has spent £86,000 on their care, the government will take over paying the cost. And by taking out specially designed insurance cover, the elderly might be able to avoid selling their homes as a result. In fact this capping system will give a bigger, more lucrative role to private insurance companies. And of course it does nothing to address the dearth of decent publicly funded social care faced by the asset-poor majority. In fact, this new Dilnot cap would benefit 100,000 mainly wealthy older people (only!), and would amount to a taxpayer transfer from the state to this group of around £2 billion a year!

   Then there is Chancellor Rishi Sunak's tax increase mainly aimed at the working class (but he is also taxing dividend income) which was presented as the way to help solve the social care crisis. National Insurance Contributions, which have gone up by 1.25% this April plus a 0.6% tax on dividends were meant to provide increase in health and social care spending of £12 billion per year: £11.4bn from the NIC levy and £0.6bn from the dividend tax rate increase.

    Except that from the outset, he made it clear that the social care sector would have to wait, because again, it was the NHS which had to come first. No lessons are to be learnt from the March to June 2020 social care death toll, when "NHS first" meant, quite literally, killing off the (very costly) elderly or, as Johnson was later heard to say: "let(ting) the bodies pile up"! So for now, 85% of the money raised, £12bn a year, is actually for the NHS. Social care will only receive £1.7bn. What is really not clear however, is where exactly the money earmarked (ring-fenced, we are told) for social care would go exactly? Is it paid to local authorities or to private establishments and on what basis?

An unfit society

It's said that a society should be judged according to how it treats its elderly. 

    And one can add, that it should also be judged according to how it treats those who care for the elderly.

    In this society and indeed in all of the rich countries, Covid merely exposed publicly what was happening all along behind the scenes. The callous neglect of those who are no longer productive. In capitalist society, based as it is on the exploitation of human labour for the surplus value it can produce, the elderly are regarded as an "unnecessary" burden. Historically, as little as possible has been spent on them.

    When pensions and personal savings grew in the post-war boom years, the elderly populations of the rich countries could be milked in their retirement for their hard-earned cash; these "assets" become a target for recycling into the pockets of so-called entrepreneurial capitalists running the care and retirement homes... That period is all but over. Defined benefit pensions have disappeared; and as the assets of the elderly shrink and private care shrinks (and increases in cost) accordingly, there will be even less care available for the middle class and none at all for the poor.

    The only answer would be to introduce a universal, free system linked to the NHS truly integrated! But the NHS itself is in crisis. The truth of the matter and history proves it is that there is no reform that will fix the situation. A totally new social system freed of profit is needed and that requires capitalism's overthrow.