Nadra Ahmed OBE, Chair, National Care Association
The key principle of multi-agency interplay between health and social care is that it must always focus on those we care for not on the process. To achieve that all stakeholders are duty bound to base decisions, not only on best interest, but also on ensuring that the safety of individuals is at the heart of it the support plan. This pandemic has exposed some deep rooted cracks in the relationships between health and social care whilst also creating synergies in the value based analysis of roles and responsibilities to those we serve, which we must embrace and build on. Additionally, it has highlighted the lack of parity in the funding issues, because as soon a patient transfers out of an NHS setting and into a social care one becoming a resident, the funding envelope drops to circa less than a third of the cost – same assessed needs, different offer! How can this be justified?
Clearly decisions made at the outset of the pandemic in March 2020, in relation to discharging individuals out of hospitals into care homes to free up bed capacity in the NHS, was a high risk strategy; even though it was badged as being safe and the risk to care homes was ‘negligible’. This was despite the fact that the virus was known to impact vulnerable people with underlying health conditions the most, putting them into a highest risk category. Care providers took the assurances given at face value and moved to support their sister organisation by accepting discharges out of hospital, thereby freeing up beds in hospitals. There was a growing anticipation that there would be of a wave of admissions based on life threatening complications as a result of this deadly virus: social care played their part to support the NHS and prevent it from being overwhelmed.
What followed was nothing short of a catastrophe for social care providers and their residents and staff. Once in the service, the infection ripped through the home. The route of entry for the virus came both from hospital discharges and the community in which the services were based. Without warning the sector faced a chronic shortage of PPE as regular suppliers to the sector were told to divert all available stock to the NHS leaving the social care providers completely exposed. Guidance on the use of PPE was chaotic to say the least and care homes found themselves in the midst of unprecedented circumstances fighting fires in all corners in an effort to keep residents and staff safe. Despite a sector wide outcry for support nothing sustainable was forthcoming, and providers saw their costs rocket as market forces intervened.
The reality of the fragility of the sector was masked by the dedication, commitment and agility of the care teams in every service as they fought to protect their residents and each other. Meanwhile, government took reactive measures to mask their lack of strategic planning to keep social care safe with proclamations of no substance. There was no plan by government to provide financial support for social care in the same way they were committing to the NHS; it would be fair to say that this pandemic has eroded the resilience of the sector leaving provision of social care in a precarious situation and on the verge of collapse.
The lessons learnt from the first four months of the pandemic were clear, and subsequent discharges out of hospitals into care settings were predicated by negative tests to mitigate the risk to the vulnerable people we care for. However, we continued to receive reports that tests were not always accurate on the date of discharge having been taken 24/48 hours before, with the individual remaining in an NHS setting. The challenge of safe discharges remained but by then providers were more challenging and less willing to risk unsafe admissions having experienced the devastation first hand.
It was months before any strategic thinking emerged to resolve the issue of ensuring capacity in the NHS, whilst keeping social care provision safe. The emerging solutions centred around a Step Down service into designated sites where Covid positive patients would be discharged to from hospitals for the required 14 nights, prior to safe admission into a care service of their choice. These sites would be funded and insured by the state having first been assured by CQC. And that is where we find ourselves now. A safe fully funded discharge methodology which needs to work in the best interest of individuals with clear pathways to long term care and support.
The impact on the sector of no direct assessed admissions has taken its toll on business viability. We are hearing of increasing voids, which for small and medium sized provision, can have a devastating economic consequence. The financial cost of the pandemic, coupled with the lack of referrals and privately funded admissions, is beginning to further destabilise business models. There has been no substantive sustainable financial support from either local or central government and the second wave has continued to erode any remaining financial resilience: increased operational costs coupled with growing funding gaps for over a decade are the recipe for a perfect storm.
As we face a second year living and working in this pandemic it is a disgrace that providers are having to face pitiful offers of fee increases yet again, increases which barely cover the uplift in the National Living Wage let alone the substantial increase in operating costs. The workforce crisis is yet to hit its peak as we witness anxieties, exhaustion and the impact on mental wellbeing suffered through the year by our workforce. Without sustainable investment in our sector recovery will be a painful path for many and some providers may not make it through. The irony of the fact there are plans to use hotels for vulnerable people leaving hospitals, at agreed rates which are circa 60% more than local authorities pay registered care providers, is not lost on us. What it tells us is that decision makers are aware of the true cost of care, they just chose not to address it.
The path to reform is littered with broken promises and half-baked ideas that lack any vision or ambition. What the sector needs is a real investment based on a strategic plan, which puts our residents and workforce at the heart of it. The time to procrastinate and appease is long gone. What we need is recognition of the value that social care provision brings and the skills of our remarkable workforce which have kept so many people safe through troubled and uncharted waters. It is time to stop throwing crumbs at the sector that is the backbone of keeping our NHS safe, and stand up to repeated manifesto promises, it is time to stop letting the most vulnerable members of our community down.