England is grappling with staggering health inequalities, with a stark 10-year gap in life expectancy between individuals in socioeconomically deprived regions and their more affluent counterparts and a cost of billions annually.
Much attention is given to the NHS; however, there is great potential and much work within the social care sector to hold the key to solving these matters. More attention must be given to address both the inequalities within this sector in addition to the population as a whole.
This report aims to evaluate the current state of the ‘causes of the causes,’ of inequalities within the social care sector and discuss ways to improve them in order to better “one of the most unequal of the world’s developed states” through population level interventions from Government.
Care England is looking to aid in solving these matters and welcomes further discussion and involvement in any future efforts.
England is grappling with staggering health disparities, with a stark 10-year gap in life expectancy between individuals in socioeconomically deprived regions and their more affluent counterparts (Office for National Statistics, 2022).
This gap is not just a moral concern; it carries a hefty economic price tag. Health inequalities cost the NHS an additional £4.8 billion annually, with a further societal cost of approximately £31 billion in lost productivity (Office for Health Improvement and Disparities, 2022). The COVID-19 pandemic amplified these inequalities, exposing a four-fold difference in mortality rates in the most deprived areas (The Health Foundation, 2021).
It is important at this early juncture to clarify the difference between inequality and inequity. While inequalities are systematic differences between groups (such as gender, ethnicity, class etc), inequity refers to differences which are unnecessary, avoidable, and considered unjust; not all inequalities are unjust, but all inequities are the product of unjust inequalities.
In the realm of public health, the connection to politics has always been undeniable. Seeking the ‘causes of the causes,’ is a quest that frequently directs attention toward political and commercial determinants of an issue. Within this context, addressing the glaring inequalities in the social care sector becomes a paramount public health concern that necessitates a population-level approach, aiming to alleviate disparities that affect individuals and the overall health of our society, further compounding to ease pressures on and better our health and social care system (Mckee, et al., 2021).
In recent decades, the Government has articulated ambitious goals to enhance health and address inequalities, yet it has frequently avoided implementation of essential population-wide policy measures. Instead of adopting national strategies aimed at fostering healthy environments for all, the emphasis has often been on encouraging individuals to modify their behaviours (Williams & Fullager, 2019).
This piece aims to evaluate the current state of the ‘causes of the causes,’ or social determinants, of crisis within the social care sector and discuss ways to improve inequalities both within the social care sector and within the population as a whole in order to improve “one of the most unequal of the world’s developed states” (Jones, 2023).
Inequalities Within the Social Care Sector
We are experiencing a crisis, previously referred to as a “ticking time bomb,” within England’s adult social care sector (BMA media team, 2022; Skills For Care, 2023). Chronic underfunding, acute staffing shortages, and an ageing population have conjoined, creating a stark reality where many individuals are already facing the prospect of being without the essential care and support they need (Spring Survey 2023, 2023; BMA media team, 2022). The challenges posed by an ageing population will only continue to further compound this crisis.
Many of the disparities within England’s social care sector draw from the structurally violent North-South divide, impacting the need for care and the access to and quality of care from both sides. Data demonstrates individuals in certain regions face disproportionate challenges in the rate of health issues in addition to in accessing and receiving high-quality care (Baker, 2019). These health conditions include serious mental illness, obesity, diabetes and learning disabilities (Baker, 2019). In 2004, roughly 30% of England’s population had a basic multimorbidity and 15% had a complex multimorbidity; however, these numbers were 53% and 32% respectively in 2019 (Head, et al., 2021). Multimorbidity, as defined by the World Health Organization as “the presence of two or more chronic conditions in a single individual,” presents distinct challenges to the design of health and social care systems that traditionally centre on managing individual conditions (Head, et al., 2021; WHO, 2016). Importantly, multimorbidity is unequally distributed and is more likely to occur in the North (Head, et al., 2021).
The divide is further exposed through various matters of funding. Local authorities in the North tend to collect less council tax because of lower property values in the region despite council tax being charged at potentially 80 per cent higher in the North than the South when property values are taken into account (Brown, 2021). As a result, there is less funding available to support care providers and those who require local authority funding.
Further, data indicates that self-funders tend to enter the social care system earlier and with lower care needs, while those funded by local authorities often enter later with subsequently potentially higher care needs (LaingBuisson, 2023). By no coincidence, more self-funders live in the South compared to the North (LaingBuisson, 2023). An ADASS report revealed that since 2021 the highest origin of financial pressure lies in the ‘unit cost of care packages to support people with increasing complexity of care needs’ (Association of Directors of Adult Social Services, 2023), highlighting another motivation to target the underlying health disparities and higher incidence of multimorbidity that affect the North. Further, in the North, fewer hours per resident per week are worked, despite the higher level of need (LaingBuisson, 2023).
The workforce challenges pose another significant barrier to achieving health equity and illustrate another ramification of the North-South divide. Staffing shortages in this sector potentially hinder patients’ access to and quality of care. The social care workforce has a clear North-South divide, with the highest average hourly pay rates recorded in London (£10.50) and the Southwest (£10.25) and the lowest in the Northeast (£9.90) and the West Midlands (£9.90) (Skills For Care, 2023).
Barriers to accessing care are a notable significant compounder to these inequalities. Such barriers include financial constraints, fear of judgment, assessment challenges, social isolation, digital exclusion, and transportation, limiting access to necessary care services (National Institute for Health and Care Research, 2023).
Efforts to Address Inequalities and Future Strategies
It is essential to recognise that addressing inequalities within wider society and the social care sector are pivotal steps in averting its current crisis state. Such attention is given to the NHS, but the public must not forget the importance of the independent adult social care sector; both due to its contributions to the wider economy, estimated at £55 billion, and the power its improvement holds (Skills For Care, 2023). Cuts in the public health grant to local authorities further hindered work to improve population health in addition to the already prevalent lower funding increases, limited funds for capital investment, and neglect of workforce planning within local authorities (Ham, 2023; The Health Foundation, 2021). By implementing policies that target the structural violence embedded within England and promote equity and access to quality care, we not only improve the lives of individuals but also fortify our capacity to provide care to the population (Mckee, et al., 2021).
Integrated Care Systems (ICSs) have emerged to address these inequalities but can be further optimised to maximize their impact (Department of Health & Social Care, 2022). Care England outlined key recommendations that would improve ICSs based on the current way their duties have been carried out in its report, From Inception to Implementation: A Year of Integrated Care Systems (Care England, 2023). For example, by permitting direct adult social care representation at both the Integrated Care Partnership or Integrated Care Board level, in addition to developing shared learning platforms to promote collaboration.
These efforts will most importantly give the social care sector a voice as well as strengthen relationships between the sector and wider partners, including Local Authorities and the NHS, which will allow for better communication and subsequent management of disease and care. This would help develop a health and care system that focuses on individuals rather than individual diseases, ultimately giving an opportunity to combat the higher rates of multimorbidity, and subsequently provide better outcomes for individuals (Policy Bristol, 2021). As said by the Secretary of State for Health and Social Care, the Rt Hon Steve Barclay MP, “our present services are not always well placed to support people with more than one risk or condition, this means that support and care can be disjointed…” (Department of Health and Social Care, 2023). To address this, restructuring and joining the health and social care sectors must be prioritized, as this intervention aims to change the system as a whole rather than change the individual needing support (Department of Health and Social Care, 2023).
The Health and Care Act 2022 gives the Care Quality Commission (CQC) new powers that allow them to provide a meaningful and independent assessment of care at a local authority and integrated care system level (UK Public General Acts, 2022). With this new power for the CQC, there is a new opportunity to hold local authorities to account, looking at specifically if they are fundamentally upholding their Care Act duties, including those relating to the reduction of inequalities.
The inability of many local authorities to pay the true cost of care has led to a two-tiered system within England’s social care sector between the North and South, deepening existing inequalities. This highlights a critical issue in the quest to address disparities within the sector. Closing the £1.5 billion Fair Cost of Care funding gap and extending this exercise to all adult social care services, as proposed by Care England’s Care For Our Future report, represents a crucial step in moving towards combatting health inequalities (Care England, 2023). Such measures are essential for ensuring equitable access to care and reducing the disparities that affect individuals and the overall health of society, aligning with the broader effort to tackle inequalities in England.
Reducing workforce issues is vital, as figures clearly demonstrate the challenges posed by staffing shortages, as highlighted in the annual Skills for Care Workforce Report (Skills For Care, 2023). The key driver of recruitment and retention challenges is pay in the adult social care sector. Care providers are limited in their capacity to pay their staff more due to underlying financial issues and sub-optimal fee rates paid to them by local authorities, with 81% of providers stating that fee increases did not cover the rising cost of workforce pay in 2022 (Care England, 2023). Central government investment into local authority fee uplifts would not only address vacancy rates across the sector but serve to improve the quality of life for care staff. It will also further benefit the economy through both an increased expenditure of the workers in addition to improving the economic productivity of individuals who will receive better care and support as a result (Care England, 2023). Addressing these workforce challenges is not only vital for the wellbeing of those in receipt of care but also to reducing health inequalities and creating a more equitable system.
In order to reverse the UK’s current trend in global rankings of life expectancy of doing “worse than all G7 countries except the USA,” efforts must be made to improve the health inequalities that ultimately lead to this figure (Hiam, Dorling, & Mckee, 2023).
Disparities within the social care sector and the wider society in England are profound and multifaceted. These inequalities arise from a complex interplay of factors, including variations in social policies and stark differences between regions, particularly the North-South regional divide. They go on to further impact other sectors within the population, illustrating a never-ending ‘cause of the causes’.
The pressures faced by the social care sector and North-South divide warrant targeting the issue through the lens of a public health approach. Effective interventions hold the potential to alleviate inequalities within England that will go further to benefit the health of the population, the workforce, and the wider economy. In this context, the focus should shift towards mitigating the progression of inequality in addition to the primary disease prevention efforts that are currently being made by the Government.
Addressing these disparities requires a broader approach that encompasses the social determinants of health and structural violence. Bridging the North-South regional divide is paramount, and it necessitates interventions at the national level. If these measures can be addressed by policymakers at the route of the problem, it will help mitigate costly reactive interventions.
Multimorbidity is the biggest cost within care packages in addition to strongly impacting mental health and NHS pressures. This suggests that aiming to alleviate its effects would mitigate these costs for the government in addition to helping improve economic activity, even wider benefiting the country.
For further information about health inequalities within the social care sector in England or Care England’s efforts to help address them, please direct to Lauren Hague (LHague@careengland.co.uk).
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