Markets, trust and governance within social care

There is a growing interest in changing the perception of social care from a burden to an economic success story.

In England alone, some 1.5 million people already work in the adult care sector and it is estimated to contribute almost £40 billion a year to the economy. Due to our aging population, demand for services is rising fast, but work needs to be done if the sector is to perform to its full potential and help deliver a truly caring society.

A key weakness is the state of local care markets. The easy excuse is lack of state funding, squeezing rates and margins and inhibiting provider investment – or at least diverting it towards self-funders – resulting in two very different tiers of service. 

But there also needs to be honesty about the largely poor standard of market oversight and regulation. Local councils have ceded responsibility for monitoring the quality of care services to the Care Quality Commission. And they have, in the main, failed to respond effectively to their soft duty – enshrined only in the statutory guidance of the Care Act 2014 – to shape a “vibrant, responsive market of service providers”.

We analysed market position statements drawn up by 27 councils to better understand the issues. In general they were sorely lacking on commissioning intentions and intervention/risk plans. Most also had a focus looking back rather than forward, playing by old rules in a broken system, and lacked any sense of an action plan or future strategy.

Lack of provision and competition

The children’s services sector offers a stark warning for adult social care if local government does not become more pro-active. As the state has reduced its direct provision, without creating adequate choice and competition among independent suppliers, a small number of providers has resulted in costs of residential care spiralling and vulnerable young people being shipped across the country in search of available capacity. In the five years to 2017, the number of out-of-borough placements by English councils soared 63% to almost 3,700.

This pattern risks being repeated in adult care unless councils take steps to ensure there is a range of good-quality services, both residential and domiciliary, available in each and every locality for both self-funders and those supported by the state. People understandably want to stay close to home if they need to move into a residential setting, within shouting distance of friends and family.

How can this be achieved in the context of a continuing funding crisis? Providers are understandably reluctant to develop new provision for the state market or upgrade existing care homes ­– eight in 10 of which are more than 50 years old – as long as fee rates remain compressed. We are forecasting average fee increases of about 4.2% in 2018/19, but more than half of this (2.5%) will go straight into covering the cost of the rise in the National Living Wage.

A caring society
A project to bring together innovative thinking, people and practice to shape a 21st Century social care system. Find out more

Adult social care insights

You can now use our intuitive tool to bring together nationwide adult social care data, understand how your council is performing and help you make better decisions for your local care population.

Structural reform through strength in numbers

Some may argue austerity has been a good and plausible excuse for inaction. I am not convinced we would be in a much better place with regard to market shaping even if the system had been awash with money since 2010. And I am increasingly drawn to the conclusion that we need something structurally different if we are to make progress.

Individual councils acting alone are unlikely to have the weight or resources to make an effective fist of market oversight and intervention. Action in concert, though, could be a different story. If councils were to come together regionally or sub-regionally, they could start to exert a real influence over local care markets. Relations with providers would improve, too, if they felt they were being treated meaningfully by a forum that had evident clout and was taking its strategic role seriously. 

These groupings of councils would be well placed to encourage the sharing of good practice, adoption of technology and creative solutions to workforce challenges. They could consider the merits and practicality of applying common fee rates for state-funded care across a region or sub-region, as is the case nationwide in Scotland. But the biggest dividend could be in bricks and mortar. By taking a strategic view of the market, these bodies could identify gaps in provision and orchestrate the borrowing of finance by councils to build new care facilities, which they would own but independent providers would run under long-term contracts.

You may say I’m a dreamer, but I think and hope I’m not the only one. As we wrestle with the many knotty problems of the social care sector, market shaping feels like a forgotten piece of the jigsaw. Yet it is so crucial. There is nothing short of a moral imperative to rehabilitate the market and then get the best out of it.

A caring society

Discover more about our programme to build a caring society  - bringing together a community who are committed to shaping the future of adult social care

Find out more