The crisis in social care: what do other countries do?
In the second of three blogs about how to respond to the social care crisis, Alan Sitkin draws on international examples as a guide to improving both the efficiency and effectiveness of social care. Germany is a country where health and social care have been partly merged but its federal structure means it has very different institutional norms from the UK. Italy illustrates one of the problems of merger and Japan one of the benefits of a continuing role for central government even with devolution.
On the supply of provision, the US offers an example of innovation by private providers when that is supported by the planning system; it also highlights some of the problems that that can bring. The Dutch ‘village concept’, first developed as a setting to support those with dementia, is aligned with the new norms of a post-Covid world. Extended to the care sector, municipal enterprise may offer a UK way of delivering innovative provision. With detail being so important, the French approach to aspects of domiciliary care are instructive.
Care for an ageing population is a global problem, particularly so in the OECD group of older industrialised nations. But the UK’s problem, namely insufficient funding at the central government level filtering down to squeeze local authorities and hence the providers to whom they subcontract their care responsibilities – is only felt in other countries with a similar multi-tiered governmental structure. How it is addressed elsewhere might therefore reveal useful policy alternatives for British politicians. The smartest operators are always those willing to learn from other smart operators.
Merger and devolution?
In Germany, healthcare and long-term care systems have been partially merged – an approach the current Conservative government has also said it might try to imitate. One of several ideas behind this semi-merger is to save money by getting currently autonomous administrations to share overheads. In a sense, it seeks to address the lack of overall care funding, not by increasing the total expenditure on care, but by subsuming care spending into a wider budget and achieving economies of scale through a more intensive use of the administrative overheads associated with it.
One of the main reasons why a semi-merger of this kind has never happened in the UK is the country’s rejection of gigantism, being the sense that transferring responsibility for care to the NHS would create a monolith. There is also a fear that cutting local authorities out of the equation will translate into greater regional inequalities and inadaptation to local circumstances – a major flaw in a country where local demographics can vary so widely. In Germany, this is less of a concern given the decentralised nature of healthcare, with 16 different state-run systems to begin with.
Although institutional ‘localisation’ can be seen to some extent in the attribution of certain healthcare and care system powers to Scotland, Wales and Northern Ireland, it does not fit with English traditions and sensitivities as well as it does German ones.
Hyper-localisation can also cause its own problems. One example is the kind of issues that Italy faces after decades of pursuing a localisation agenda, reflecting that country’s longstanding regional fragmentation. The end result in Italy has been a potpourri lottery code of care quality and funding, recently resulting, for instance, in tremendous variation in the efficacy of Italian regions’ response to Covid-19. This approach also comes with a wasteful and bureaucratic duplication of administrative overheads, adding to the ongoing deficits from which Italy has suffered for years. The value of micro-level solutions is diminished if they aggravate macro-level problems.
The question is whether the optimum may be found at an intermediate level, enabling both responsiveness and scale – a compromise that could theoretically be achieved in the UK by the new combined authorities that are still only taking shape. Until now, the devolution agenda has largely focused on education and economic regeneration. Councils may wish to study how care could fit into the mix – with special consideration given to facilitating care workers’ cross-borough commuting needs.
This is not to say that lodging care – whether or not it is combined with healthcare – in sub-regional entities eliminates the need for national or local level intervention. In Japan, for instance, despite a certain delocalisation, central government continues to contract certain care services nationally, forming a kind of purchasing combine enhancing the bargaining positionof the country’s prefectures (these being the Japanese mid-level of governance closest to the combined authorities). A centralised negotiation of procurement would help the UK care system’s finances by strengthening the hand of the representatives negotiating goods and services that can only be sourced from large corporate interests.
Large scale provision?
An asymmetry also exists when cash-strapped local authorities impose low payments on small- and medium-sized providers, increasingly to the point of de-incentivising the latter’s participation in the care market. To counter such shortages, local authorities may wish to look to the US example, where planning empowers providers to develop large purpose-built facilities capable of achieving significant economies of scale, this time at the point of delivery. It is true that even as scaled-up care homes solve certain challenges they also create others, specifically an opportunity for private oligopolies to engage in price-gouging and/or impose excessive returns (as witnessed by the actions of certain American private equity funds which have recently entered the British care market).
There is also a risk that private mega-facilities may cut corners and reduce provision quality – being one reason why this approach would have to be accompanied by the establishment of a standards body; but also, conceivably, by sub-regional bodies and/or their local authority members stepping into the breach and assuming a prime contractor’s role leading these initiatives.
Several innovative shared public-private ownership models – designed to satisfy a public mission remit – already exist in the UK, for example, for the refurbishment of industrial estates, and social housing. They have been galvanised by the successes of a few trailblazers in this area, including both the London Borough of Enfield after 2010, and Preston City Council. With a few modifications, the lessons learnt in this respect can be transferred more or less wholesale to the care facilities development sector. Municipal entrepreneurship is an increasingly attractive policy orientation for councils nationwide, one that has yet to fully extend to the care sector. It is time for that to happen.
If one accepts a future proliferation of mega-care facilities in the UK, the question becomes where they might be located. One option is the village concept developed in the Netherlands, originally to cater to dementia patients but also entirely applicable to all stages of care. Locating these kinds of villages on urban outskirts reduces land acquisition costs. The problem associated with their distance from existing town centres can be obviated by implementing a holistic place design including high street amenities – in line with the de-densification agenda likely to dominate spatial planning in the UK like many other countries post-Covid.
It is in this way that creative combined authorities, other sub-regional entities and/or local authorities might look to subsume part of their overall care provision into wider economic regeneration programmes – producing the added benefit of breaking down interdepartmental silos and creating opportunities for further savings through the integration of information systems (a whole other domain rife for innovation in the UK public sector).
The opportunities for change revealed through these examples largely materialise at a macro-level encompassing care systems’ structural, institutional and financial needs. Yet micro-level interventions will remain as important as ever, one example being the different ways in which domiciliary care might be provided, a sub-topic that can also be enriched via international comparison. One example here is the French reticence for the expensive “meals on wheels” service that is so widespread in the UK, replacing this service where possible with approaches that are also intended to reduce users’ isolation, including by accompanying them to institutional dining halls. This solution has the added benefit of using large-scale consumption to reduce healthier meals’ preparation costs.
UK local authorities might also benefit from mapping elderly care receivers’ demographics to those of their care givers. This generates value by converting previously transactional relationships into connections rooted in social exchange value.
The point to remember is that even before Covid-19 began wreaking havoc on our elderly populations, demographic trends were already creating tremendous pressure on national care systems worldwide, generating a host of imaginative responses that could well be transferable to the UK. The country’s most forward-looking local authorities have always been willing to import best practice in response to the policy challenges they face. It is time for this mindset to extend to care.