Adult Social Care in England and Birmingham – and how the Council can take it out of the market

These are Notes for a talk by Richard Hatcher at Birmingham Trades Council’s May Day event, 2 April 2020

We all have experience of doctors’ surgeries and  hospitals. Most of us have little experience of adult social care. (I’m not going to include children’s social care which raises different issues.) It has taken the pandemic to make people more aware of the social care system – the number of deaths the shortage of PPE, the risk to dedicated staff.

The Guardian on 28 April reported that ‘More than 4,300 people in care homes across England and Wales died from Covid-19 in a fortnight… Half of them came in the last five days, indicating an accelerating death toll.’

BirminghamLive on 24 April reported that Jack Dromey, MP for Birmingham Erdington, said he had surveyed the 47 care homes in his constituency and found “deeply worrying staffing levels, inadequate provision of PPE and limited access to testing for care home staff.”

An article a week earlier, on 17 April, reported that the city council has called on the government for urgent action to protect at-risk staff and residents – ‘The situation is critical’.

‘Last week, for example, a long awaited supply of kit was woefully short – with 60% less equipment than the council had said it needed. If demand for protective facemasks continues as predicted, the city council’s stock of approximately 38,000 masks will only last for a further two weeks for use in priority areas, the council adds – never mind supplying additional services that might need kit.’

As part of its response to COVID-19, the UK government announced in the Budget on 11 March that it would provide local authorities in England with £500m of new grant funding, but this is a drop in the ocean.

Forms of provision of adult social care

 There are four forms of ASC provision:

  • Residential care homes

There are 15,517 residential care homes in England, with an estimated 457,361 beds. That compares with about 200 hospital trusts. Most care homes are privately run.

Occupancy rates seem to be about 90% which would suggest there are about 411,000 people living in care homes in England and Wales. There is no official data on the exact number of residents.

  • Domiciliary care in people’s homes

Each week in the UK, it is estimated that 540,000 people receive support in their own home. That adds up to a million home-care visits happening each day. What’s provided on these visits can range from help going to the toilet, to preparing a meal or support with medication. A 2016 UNISON survey found that more than half (58%) of domiciliary care workers have been given just 15 minutes or less to provide personal care, sometimes for people they had never met before. The majority (74%) said that they do not have enough time to provide dignified care.

  • Individual personal support assistants

Around 70,000 disabled people in England employ Personal Assistants to help them live the kind of lives others take for granted. between them employ 145,000 PAs.

  • Day and community care

Who pays?

Unlike the NHS, funding for social care is provided through local councils. And also unlike the NHS, ASC is not free for all. Some services are provided free but most are means-tested. The savings threshold for local authority funding in England is £23,250. Elderly and disabled people with assets above the threshold do not receive help from local councils towards care costs.

The workers providing adult social care in England

  • 465,000 work in care and nursing homes
  • 610,000 provide care in people’s homes
  • 150,000 provide day and community care

The total is over 1.2million. That is about 4 times the  320,000 nurses in the NHS. The care sector has always struggled to recruit enough staff because of its reputation for low pay and the lack of recognition. It’s estimated that there are currently 122,000 full-time equivalent vacancies in England.

It’s also the case that union membership in social care is much lower than in the NHS.

Adult Social Care in Birmingham

 The total Birmingham workforce is 520,000. Adult social care is one of the largest sectors, with 29,000 jobs – 5.6%. That compares with 19,500 in construction – 3.8% – and is not that far short of the number of jobs in manufacturing, 38,000 – 7.3%. Adult social care makes up 17.8% – about I in 6 – of the 163,000 public sector jobs in the city.

In the West Midlands 77% of ASC workers are employed in the private sector and 7.5% directly by local authorities. The percentages are likely to be similar for Birmingham.

 According to the figures for Birmingham in ‘The state of the adult social care sector and workforce in England’, Skills for Care Workforce Intelligence, October 2019:

  • 80% of workers are female, 20% male.
  • 53% are White, 47% BAME.
  • 81% have British nationality, 6% EU, 13% non-EU.
  • 59% had a qualification relevant to social care.
  • 49% of jobs were full-time, 37% part-time, neither 14%.
  • 26% of workers were employed on zero-hours contracts (or 7,100 jobs)
  • The turnover rate in 2017/18 was 34.8% (or 8,700 leavers).
  • The vacancy rate in 2017/18 was 5.7% (or 1,500 jobs).

The privatisation of adult social care

 According to Ownership in social care: why it matters and what can be done, a report by the New Economics Foundation in 2019:

In the 1970s social care services were largely delivered by the state. Today services are almost entirely outsourced, with the private for-profit sector playing the biggest role. In residential care, for example, 83% of beds are provided by for-profit organisations, 13% by the voluntary sector and 4% by local government or the NHS.3 Both public and private money is spent on these services. In 2016/17 the total value of care arranged by local authorities was £20.4 billion, while care purchased by those who self-fund without local authority involvement amounted to £10.9 billion.

Domiciliary and residential care markets remain relatively dispersed, but there is a longterm trend for smaller providers to be bought out by large chain companies. The biggest four residential care companies, for instance, are responsible for 15% of  residential care provision, and just under a third (31%) of all beds are provided by the biggest 25 companies. (p5)

Adult Social Care in the Birmingham Council budget

Social care is the Council’s biggest area of expenditure: about £330m, which is about 40% of the Council’s controllable budget. The majority is spent on contracts with private providers of care homes and supported living. They are listed on the Council website. They total 705 contracts, comprising 434 Care Homes and 271 various supported living contracts. There is no information on the Council website of who the owners are of the 700 providers, with a few exceptions.

In 2017 the New Economics Foundation with Localise West Midlands published a report, Social Care as a Local Economic Solution for the West Midlands. It explains how the social care market is dominated by a small number of large private providers.

The increasing dominance of large-scale providers, with debt-laden business models, is a major vulnerability.

Built into every contract to a major provider will be the underlying need to deliver a significant return on investment – CRESC found that big care providers expect to offer 11% returns to investors (including costly debt repayments which often return to the parent operating company). The business models of the largest five residential care chain companies in the UK offer returns to investors that account for as much as 29p in every £1 of their costs – the second biggest drain on expenditure after wages. (p10)

(CRESC is the Centre for Research on Socio-Cultural Change. In 2016 it published a detailed analysis of the social care market: Where Does the Money Go? Financialised chains and the crisis in residential care.)


 According to a recent Resolution Foundation report, half of frontline care workers – about 1million workers, are paid less than the real living wage (£9.30 an hour outside London). Tens of thousands also appear to be being paid illegally below the national minimum wage.

  • The average hourly rate for jobs in the local authority sector in September 2017 was £14.13, compared to £8.75 in the independent sector in March 2018.
  • On average, pay in the local authority was £6.63 higher than the National Living Wage (£7.50).
  • On average, pay in the independent sector was £1.25 higher than the National Living Wage.

The Care Quality Commission report speaks of concerns about care homes being inadequately staffed to safely support and care for the people living in them. Care workers have told us they were working chaotic and unorganised shift patterns, at times without breaks, causing many to feel dissatisfied, stressed and undervalued in their caring role. A similar picture has been given in domiciliary care services, with feedback about managers taking on new care packages at times when care workers’ existing rotas were already too challenging for them to manage safely. We have heard of situations being made worse when care workers have decided to leave and were not replaced, or were replaced by inexperienced or unskilled staff.

We need a national campaign for Social Care

In Health we have KONP and the umbrella campaign Health Campaigns Together. We need a parallel national campaign for Social Care. In Birmingham we had the strikes by Enablement workers over contracts, but it wasn’t part of a national campaign for social care and it didn’t lead to an ongoing campaign after the dispute was settled. We must take the opportunity of the pandemic to build an ongoing campaign nationally and in Birmingham.

Over the past year national planning meetings have been taking place in Birmingham to set up Reclaim Social Care, with a mixture of SC activists and professionals. Reclaim Social Care was planning a national launch meeting in a few months but of course it’s had to be postponed. The campaign has published the following manifesto:

Social Care should be

  • A universal service, available to all on basis of need, and free at the point of use to all who need it
  • Fully funded through progressive taxation
  • Publicly provided
  • Subject to national standards
  • Locally provided, locally accountable and designed as far as possible by service users
  • Addressing people’s aims, aspirations and choices not just bare needs
  • Providing staff with training, qualifications career structure, and decent pay
  • Giving informal carers support and respite care as required.

This means getting the market out of Adult Social Care

The 2017 NEF report Social Care as a Local Economic Solution for the West Midlands argues that what people want is smaller-scale provision offering personalised care, and community care by small local organisations is ideally suited to cooperatives, social enterprises and other forms of non-profit provision. These types of organisations, unlike the big profit-driven private providers, can exemplify the participatory model of ‘Democratic Public Ownership’ that the Labour Party has advocated.

The 2019 NEF report Ownership in social care: why it matters and what can be done makes four ‘Recommendations for local government’:

  • Direct a growing share of social care funding each year to public sector, cooperative and community-based providers
  • Build capacity within local authorities and the voluntary, community and social enterprise sector to play a greater role in the provision of care
  • Develop collaborative, rather than competitive, forms of commissioning
  • Commission for co-production, opening up the commissioning process to people needing support and their families, and using commissioning to 14 Ownership in social care: why it matters and what can be done encourage local providers to design and deliver social care services with the people intended to benefit from them.

This is the model advocated by the Social Services & Wellbeing (Wales) Act 2016, which ‘places a duty on local authorities to promote co-operatives, social enterprise, user-led and third sector organisations for social care, and also seeks to ensure that citizen-users of social care have a “strong voice and real control”.’ The Social Co-operation Forum, funded by the Welsh government, ‘believes that user-led and multi-stakeholder co-operatives, embracing co-operative principles of democracy and co-ownership, are ideal models for achieving the Act’s aspirations.’

Getting the market out of adult social care is supposedly already the policy of Birmingham’s Labour Council. Building a Better Birmingham: Labour’s Local Manifesto 2018-2022, published in March 2018, gave the following commitment under the heading ‘A Rebirth of Municipal Socialism’:

We will re-state the case for the municipal provision of services in Birmingham, heralding a new age of municipal socialism.

And the Labour council in Birmingham will lead by example, calling time on the misplaced notion that the private sector always trumps the public sector by adopting a policy of in-house preferred for all contracts. (p6)

Since then I can find no evidence of the Council pursuing this policy. We need a campaign in Birmingham to demand that the Council puts its policy into practice.

How could a public non-profit adult social care system in Birmingham be run?

The important point here is that even under the present Conservative government local authorities could and should use their powers of procurement to allocate as much as possible of their social care budget to non-profit providers with participatory models of management involving service users and workers. Birmingham Council could stop funding for-profit providers as their contracts come to an end and rebuild capacity in the not-for-profit sector. This would ensure standards for clients and staff and save money because it wouldn’t be paying for private profit.

One option would be for provision to be provided directly by the local authority. But by far the best option, in line with the recommendations of the 2019 NEF report and the Social Co-operation Forum  in Wales, is the multi-stakeholder cooperative model – a joint partnership between the Council, care workers, adult social care users and community organisations. It could be organised as one single partnership, or two – one for care homes and one for home support. Or it could be composed of a number of smaller partnerships set up on an area basis within the authority.

Key strategic policy decisions should be the responsibility of the council, including the funding of provision, quality standards, workforce pay and conditions, and the powers of workers and of service users. This should be based on genuine co-production. That would require participatory democracy at the strategic policy level of the council to enable service users and service workers to have an effective say in the strategic policy framework.

First step: a public audit of current providers

The two key Councillors responsible for ASC are Paulette Hamilton, Cabinet member for health and social care, and Rob Pocock, Chair of the Overview and Scrutiny Committee for health and social care. One or both should carry out an immediate audit, with the results made public, of all care providers contracted to the council, listing:

  • The cost of each contract
  • The owners of providers, including not just the immediate owners but who owns the owners
  • The numbers of clients
  • The ratio of staff to clients
  • The qualifications and pay of each grade of staff
  • The number of vacancies

 A participatory model of how social care in Birmingham should be run

The Council has a policy of participation – ‘co-production’ – in social care at the local level, making use of community support and facilities in the neighbourhoods. But we also need effective participation by social care clients and workers and support organisations at the top level, in the Council House where the key decisions are made.

The Council has taken one small step in that direction by setting up the monthly Adult Social Care Citizens’ Co-Production Forum. These are open meetings attracting 50 or more social care users and professionals, but they are carefully stage-managed largely by officers, so there is no analysis of the crisis in ASC and the current situation in Birmingham, no challenge to government policy, and no opportunity for collective participation in decision-making. And the unions choose not to attend.

What could real participation mean? There are three reforms which Birmingham City Council could put into practice tomorrow, even under the present government:

  1. Transform the Forum meetings into a genuine democratic discussion about the current situation nationally and in Birmingham with proposals for action.
  2. Set up a Council advisory committee on ASC, chaired by the Cabinet member, with representatives of service users, service workers and unions, and community prganisations – perhaps elected from the Forum.
  3. Invite representatives of service users and workers to take part, in an advisory role, in the Health and social Care Scrutiny Committee.

Together these three reforms would give everyone a real voice in how social care in Birmingham is run.



Ownership in social care: why it matters and what can be done

Social Care as a Local Economic Solution for the West Midlands

Where Does the Money Go? Financialised chains and the crisis in residential care

For more on co-production see ‘Co-production, social care and participatory democracy’, 5 September 2019:

Reclaim Social Care and Facebook



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