From Provider to Enabler of Care? Reconfiguring Local Authority Support for Older People and Carers in Leeds, 2008 to 2013

Abstract

This article explores developments in the support available to older people and carers (i.e., caregivers) in the city of Leeds, United Kingdom, and examines provision changes during a period characterized by unprecedented resource constraint and new developments in national-local governance. Using documentary evidence, official statistics, and findings from recent studies led by the author, the effects of these changes on service planning and delivery and the approach taken by local actors to mitigate their impact are highlighted. The statistical data show a marked decline in some types of services for older people during a 5-year period during which the city council took steps to mobilize citizens and develop new services and system improvements. The analysis focuses on theories of social quality as a framework for analysis of the complex picture of change related to service provision. It concludes that although citizen involvement and consultations exerted a positive influence in delivering support to some older people and carers, research over a longer timescale is needed to show if these changes are adequate to protect older people and carers from the effects of ongoing budgetary constraints.

Introduction

This article explores developments in the city of Leeds, United Kingdom, in the period 2008–2013 and their impact on the support available to older people and carers. It focuses on a period of significant change, involving substantial new resource constraints, alterations in the relationship between central and local government, and a shift in national policy affecting people who receive welfare payments. The topic is important because the city is one of many in England, and indeed throughout Europe, facing growing demand for older people's services in the context of significantly reduced budgets. Although the findings are specific to one urban setting, they are relevant to wider debates about how this increasingly familiar dilemma can be addressed. Assisting older people with social care needs is a statutory responsibility for local authorities in England, and, thus, in Leeds for its city council, although across the country support and services for older people and for carers is often delivered through contractual commissioning arrangements between local authorities and voluntary or private sector organizations and, in some cases, with parts of the National Health Service (NHS).

Overview of Challenges Affecting Local Social Care Servicesces

In England, the period 2008–2013 began with the global financial crisis of 2008 and included a change of national government in May 2010 (when a Conservative-led Coalition Government replaced the three successive Labour administrations that had held power since 1997). The financial crisis had substantial repercussions in Leeds, as employment in the city had been concentrated in the financial and public services throughout the previous decade and job losses in these sectors affected many local residents, particularly women (Yeandle & Joynes, 2012). It was the national austerity measures adopted by the incoming government, however, that had the greatest impact on Leeds City Council's budget, creating major challenges in maintaining and developing support for older people and carers.

Over the same time frame, the central government took various steps that altered the powers and autonomy of English local authorities. The changes included new national-level retrenchment in welfare state provision and other developments through which the national state gave local authorities new powers but also imposed new constraints upon them (Kispeter & Yeandle, 2015). Local-regional economic and social planning and investment arrangements were also changed, via the Public Bodies Act 2011, which abolished the English Regional Development Agencies (RDAs), including Yorkshire Forward, based in Leeds. The new Local Enterprise Partnerships (LEPs), which replaced RDAs (focused on the Leeds City Region in Leeds), had a stronger emphasis on economic than on social issues (Bentley, Bailey, & Shutt, 2010; Hildreth & Bailey, 2013).

These changes and developments challenged aspects of social solidarity and exacerbated socioeconomic inequalities but also gave rise to some new local responses and created some opportunities for citizen participation. In Leeds, the city council took a range of steps to identify citizen preferences and priorities at the grass roots. Through their mobilization and activities, some local actors, voluntary organizations, and pressure groups gained new opportunities to influence and affect certain decisions about, and developments in support of, older people and carers.

The following paragraphs focus on the pressures affecting all English local authorities, including Leeds, and set the scene for the city-specific analysis that follows. Subsequent paragraphs describe how the theoretical framework can be used in exploring the data available in four studies of services for older people and carers in Leeds led by the author, which analyzed policy developments, collected new empirical evidence, and examined official data to address questions about how support for older people and carers was changing. Information explored includes: who gets support, and of what kind; how support is supplied and paid for; and how the arrangements in place affect choice for older people and carers in the city. The third part of the article focuses on demand, constraints, and three specific aspects of support offered by Leeds City Council: home and day care services for older people living at home; the Council's Telecare Service; and the resources and assistance offered to carers. The article concludes by considering the implications of the evidence presented and discussing these in the context of the four aspects of social quality.

Financial Constraints and Other Pressures Affecting English Local Authorities in 2008–2013

The income of English local authorities, through which they fund their adult social care and other services, comes from several sources. Most important are central government grants (derived from general taxation) and its redistribution of nondomestic rates (which are collected by local authorities from local businesses and passed to central government). These represented 61% of English local authorities' total income in 2007–2008, 64 % in 2010–2011, and 63% in 2012–2013 (CLG, 2012). Other major sources of local authority income are locally funded, and include Council Tax, based on property values, payable by local residents; rents on council properties; and charges and fees (for services provided), which include the charges and copayments applied to chargeable adult social care services. The latter are levied at the discretion of the local authority and calculated on the basis of the service user's income or wealth (under rules set out in national guidance). Citizens on low incomes or with few assets, but eligible for support on grounds of assessed need, are exempt from most charges for adult social care.

After the May 2010 general election, the newly elected Coalition Government quickly introduced an emergency budget, in which “the scale of the cuts … came as something of a shock to senior officials [in local government]” (Hastings et al., 2013, p. 8). In its subsequent Comprehensive Spending Review 2010, it set out an austerity program and a 4-year deficit reduction plan. This plan included measures that strongly impacted English local authorities (Ward, 2013), whose grant income fell from £107.3 billion in 2010–2011 to £97.7 billion in 2012–2013. Locally funded council income could rise only slightly to offset this as central government imposed a new system of Council Tax freeze incentives and penalties for councils that chose to raise Council Tax (Adam & Brown, 2012). Seeking to balance their books, many local authorities made difficult decisions, including increasing user fees and copayments for care services. Between 2008–2009 and 2012–2013, income from adult social care fees and charges rose nationally by 12.5%, from £2.3 billion to £2.6 billion (DCLG, 2014, p. 62). This approach could not bridge the gap, however, and in many cases, large-scale service replanning was introduced.

Steps taken by local authorities to make expenditure savings at this time included a sharp reduction in their annual capital expenditure on elderly residential care, which fell from £103.3 million in 2008–2009 to £46.9 million in 2012–2013 (a cut of 55%) and in their capital expenditure on elderly day care, which fell by almost a third (from a peak of £17.7 million in 2009–2010) to just £12.2 million in 2012–2013 (DCLG, 2014, p. 201). The harsh reality of local authorities' financial situation after 2010 is evident in overall figures, which show that in just 2 years (2010/2011 to 2012/2013), their total income fell by nearly £10 billion (DCLG, 2014, p. 35).

These headlines on local authority finances summarize complex changes that are not the main focus of this article, but demonstrate the scale of the cuts local authorities in England faced. They occurred in a context of upward demand and demographic pressure, including the rising older population, and led to substantial change in many English local authorities. By 2015, overall local authority spending had been cut by 29%. Cuts were not evenly distributed between local authorities, however, and were considerably greater in the North and Midlands than in the South (Hastings et al., 2013, p. 7).

The period 2008–2013 also saw significant and complex changes in other aspects of the relationship between national and local government. Employing an explicit rhetoric of decentralization, central government claimed that through the Localism Act 2011 it was giving local authorities and local communities more power over the kinds of local services they could offer, stating:

The Government is committed to passing new powers and freedoms to town halls.…Local authorities can do their job best when they have genuine freedom to respond to what local people want, not what they are told to do by central government. In challenging financial times, this freedom is more important than ever, enabling local authorities to innovate and deliver better value for taxpayers' money. The Localism Act contains a number of proposals to give local authorities new freedoms and flexibility. (CLG, 2011, p. 4)

In fact, the Act gave increased local control only if services were “improved” or became “more competitive” and brought a complex mix of new centrally imposed controls and freedoms. Local authorities acquired a new “general power of competence” and the “freedom” to hold referenda to test the willingness of local citizens to accept local taxes above the level authorized by central government. They also became subject to a new “community right to challenge” (CLG, 2011).

At about the same time, the Welfare Reform Act 2012 brought significant changes to the UK's welfare system. In Leeds, the city council began planning for these after publication of the Government's White Paper Universal Credit: Welfare That Works (2010), which set out the intended direction of legislative change. Implementation of the reforms enacted in 2012 began in 2013 and included a new benefit, Universal Credit, designed to replace most other income support or income-related benefits, including Income-Related Jobseeker's Allowance, Housing Benefit, and Tax Credits (Local Government Association, 2012). The Act also replaced Council Tax Benefit with new locally managed rebate schemes and required local authorities to make 10% savings on previous arrangements. Councils were free to choose their own means of achieving savings, but their new schemes had to protect the incomes of older people. They also acquired new discretion in supplementary schemes for citizens on low income, from April 2013, as the 2012 Act abolished the national Discretionary Social Fund (through which a central government agency funded crisis loans and community care grants) and gave them responsibility for its replacement. While some central funds were provided to support them in this action, the new support was not ring-fenced and created difficulties for authorities facing substantial cuts and budget pressures. Overall, the Leeds economy is estimated to have lost £228 million per annum through the changes to welfare benefits introduced in the 2012 Act, the equivalent of a loss per working age adult of £450 per year (Beatty & Fothergill, 2014, p. 8).

The developments just described occurred alongside a continuing national policy on ageing in place for the country's expanding population of older people, an approach that long predated both the financial crisis and the Coalition Government, and had been a key element of social services modernization under the Labour administrations of 1997–2010. Most local authorities were, therefore, already committed to providing more care outside residential or hospital settings, and (as indicated later) in Leeds the city council already had a policy of supporting carers and of increasing the use of assistive technology to help older people remain independent at home (DH, 2006; 2010a, 2010b).

These social, political, and economic developments inevitably affected local services provided to older people and carers, for which local authorities remained responsible. This article now uses data from studies led by the author during this period of major change to address the question, “How did provisions for older people and carers change in Leeds during this period of unprecedented resource constraint and significant changes in governance?”

Studies of Support, Services, and the Circumstances of Older People and Carers in Leeds

The studies on which the article draws used mixed methods approaches, involving empirical qualitative and quantitative data and analysis of existing secondary data. Fieldwork methods included research interviews, observation, and local stakeholder perspectives, while other evidence was derived from analyzing policy documents, management information, local government monitoring returns to central government, responses to freedom of information requests and Census of Population data collected in 2001 and 2011.

The Carers, Employment and Services (CES) study was undertaken in 2006–2007 and funded by the EU EQUAL Community Initiative Programme as part of the Action for Carers and Employment project led by the national charity Carers UK. It included a national survey of over 1,900 carers; statistical work on existing datasets (including the 2001 Census) to assess demand for care in selected localities (including Leeds); explored the provision of unpaid care to older, frail, and disabled people at the local authority level; and reviewed the support available to carers in Leeds (Yeandle, Bennett, Buckner, Fry, & Price, 2007a).

A related study, funded in 2008–2009 by the Department of Health, produced profiles of the nine English regions to support implementation of the UK government's 2008 National Carers Strategy (NCS), an interdepartmental commitment to improve services, support, and working conditions for carers (HMG, 2008). The study analyzed regional statistics on demand for care and on carer characteristics and circumstances, and research output included a profile of Yorkshire and the Humber (where Leeds is located) (Buckner, Fry, & Yeandle, 2009).

The FLOWS study (http://www.flows-eu.eu/), conducted in 2011–2014, explored women's labor force participation and the local welfare state in 11 European cities, including Leeds. It focused on how local welfare systems, such as services for older people and support for carers of older, sick, and disabled people, affect women's employment and their family lives. It also included an analysis of local policy formation and local political actors (Yeandle and Joynes, 2012; Kispeter & Yeandle, 2013; Kispeter & Yeandle, 2015).

The AKTIVE project (Advancing Knowledge of Telecare for Independence and Vitality in Later Life) was an academic-industry partnership developed in 2011–2014 in collaboration with two English local authorities, including Leeds City Council. It studied older people using the Council's Telecare Service, and explored how technological support for older people susceptible to falls or with memory problems affected their everyday lives. It included a focus on the telecare system in Leeds and the policy underpinning it, which included the Council's decision in 2012–2013 to consult on and subsequently introduce a charging policy for this previously free service (Yeandle, 2014a; Yeandle et al., 2014).

Based on these studies, this article summarizes data on older people and carers in Leeds and highlights some of the changes in support and services available for them: the home care and day care services for older people arranged through the Council's Adult Social Care department; its Telecare Service; and its arrangements for supporting carers.

Changes in Support for Older People and Carers

Social Quality as a Framework for Analyzing Change

The data underpinning the argument of this article, described below, have been explored by applying theoretical ideas associated with the search for an understanding of how “social quality” can be defined and/or achieved in European societies (Beck, van der Maesen, & Walker, 1998). Theories of social quality emphasize four factors: a bottom-up approach that pays attention to the experiences of citizens; the daily lives of citizens and the economic and social processes that affect them; issues of both quality and cost efficiency in planning and evaluating policy; and the role of any “coalitions and solidarities” that emerge to address inequalities and risks. Advocates of this approach claim it “encompasses objective and subjective interpretations of the everyday life consequences of economic, social, cultural, and political processes” (Beck et al., 1998, p. 318).

The theoretical focus here is, thus, on macro-micro level tensions and the roles of institutions, communities and citizens as agents of change, targets of policy-making, and differentially empowered/disempowered social groups. Some commentators see the “individualization of the social” as a crucial factor and potential threat to social quality (Ferge, 1998, p. 188). Others claim a focus on social quality provides “the essential link between action, need and policies” by conceptualizing the individual as an “active subject living in developing social conditions” (Wallace & Abbott, 2009).

Older People, Carers, and Expenditure on Social Care Services in Leeds

Census of Population data collected in April 2011 provides an overview of Leeds' elderly, sick, and disabled population and of its citizens who provide unpaid care to others, as all residents were asked about their health status and caring activities (ONS, 2013). Comparison with similar data from the 2001 census shows that over the decade, Leeds' population aged 85 years or older grew by almost 9%, from 13,378 to 14,582. In the same decade, the proportion of Leeds residents caring intensively (for 20 or more hours per week) also increased (from 3.1 to 3.5%), although the overall percentage providing unpaid care fell slightly (from 9.8 to 9.5%).

By 2011, Leeds had a total population of 751,482 people, among whom 14.5% were aged 65 or older and almost 2% (9,849 women and 4,733 men) were aged 85 or older. Almost 17% of the city's residents (125,678 people) had a health condition that affected them in daily life: 59,155 had a disability or health condition that limited their day-to-day activities “a lot,” and 66,523 a condition that limited their day-to-day activities “a little.” In addition, more than 1 in 20 residents (40,652 people) reported serious concerns about their own health: 31,504 (4.2%) described their health as “bad” and a further 9,148 (1.2%) as “very bad.”

Within the city's population aged 25 to 64 years, 50,938 said they regularly provided care to an older, sick, or disabled person, including 16,747 people caring for 20 or more hours each week. These carers were split almost equally between those aged 25 to 49 (61% of whom were women) and those aged 50 to 64 (among whom 59% were women). Most carers in the 25–64 age group who cared for 20 or more hours per week were women (9,916, or 59%), but a large minority (6,831, or 41%) were men. Leeds residents providing unpaid care included almost 25,000 people providing care while also holding a full-time paid job and 12,500 (mostly women) caring alongside a part-time job.

Demand for services relevant to older people and carers was, thus, significant and growing, as Leeds City Council was well aware (see below). However, under the national austerity measures already described, the Council had to reduce its overall revenue budget by 11% in 2011–2013, making savings of £90 million in 2011–2012 and of a further £55 million in 2012–2013. Its Annual Statements of Accounts for the period 2008–2013 show that net expenditure on adult social care rose sharply between 2008/2009 and 2009/2010 (from £181 million to £247 million) but, coinciding with the new government's austerity measures, fell back sharply, to £237 million in 2010/2011 and to £196 million in 2011/2012 (stabilizing at £198 million in 2012/2013).

The budget reductions, which affected all areas of service provision in the city, included measures that impacted on adult social care services in particular ways. Four day centers for older or disabled adults were closed, some fees charged to service users were raised, and some grants were cut back or terminated (Leeds Community Foundation, 2013). Official data on Leeds City Council's “gross current expenditure” on Adult Social Services show that, between 2011–2012 and 2013–2014, expenditure on day and domiciliary care for older people fell from 38% to 27% of the relevant budget (HSCIC, 2014a). Meanwhile, the percentage of its adult social care expenditure allocated to residential and nursing care for older people rose from 52% to 61% and that which was allocated for the “assessment and care management” of older people rose from 10% to 12% (HSCIC, 2014a).

These figures indicate the direction of change in service provision for older people and reflect changes in the home care, telecare, and carer support services to which this article now turns. Faced with the financial challenges outlined, Leeds City Council, with its partners, sought to mitigate the changes and protect the city's most vulnerable citizens. Articulating a vision for improving support for older people and carers through its best council plan, which emphasized “helping local people with care and support needs to enjoy better lives” (LCC, 2014a), its approach was to develop some new services designed to deliver support to older people and carers in different ways (discussed below).

Home Care and Related Support for Older People

Between 2008/2009 and 2013/2014, the number of people aged 65 years or older receiving home care arranged by Leeds City Council, already rather small, fell by 24%, from 4,825 (or 445 per 10,000 people) to 3,680 (320 per 10,000 people). Over the same period, its expenditure on home care (for all age groups) more than halved, falling from £28.6 million in 2008/2009 to £13.1 million in 2013/2014 (NASCIS, 2015).

In a related development, outsourcing of home care services also proceeded apace. Outsourcing care services (sometimes through privatization, sometimes through commissioning arrangements with voluntary and not-for-profit organizations) has been a strong trend in England in recent decades, evident in Leeds as elsewhere. Thus, whereas in 2006 Leeds City Council itself provided 23,479 home care hours (79%) and the independent sector provided 6,351 hours (21%), by 2011 this situation had effectively reversed, with the independent sector and local authority providing 23,984 (75%) and 8,024 home care hours (25%) hours, respectively. Before 2010, Leeds City Council reported that much home care was provided by its own “relatively large, in-house” community support service, alongside a “block contract with six external providers.” However, in November 2010, the Council, with local NHS organizations, agreed on a framework agreement with 36 independent sector home care providers, and restructured its community support service to deliver a “reablement” service as well as a (much smaller) long-term service (LCC, 2012a, p. 16). It claimed the new arrangement offered extended “customer choice,” increased capacity, provided “outcome focused” support, and “achieved affordable prices” leading to “efficiencies for ASC” (adult social care). It highlighted the reablement service (which supports mainly older people following hospital discharge) as a particular “success story” for the city, reporting that it delivered a 62% “average reduction of care hours over the programme of reablement” and had been successful in enabling 70% of “reablement customers” to cope without requiring an ongoing package of care after their (typically 6-week) reablement service ended (LCC, 2012a, p. 19).

As individual budgets were introduced (also in response to central government guidance), Leeds City Council also reported growing use of these budgets, with service users either taking them as direct payments (cash payments allowing them to purchase their own services) or using them to employ their own personal assistants. The total number of people using individual budgets in Leeds rose from 757 to 1,083 between August 2010 and August 2011 alone, with growth in the use of personal assistants driving most of this increase (LCC, 2012a, pp. 18–19).

During these years, other services used by older people with support needs living at home declined. The number provided with meals at home fell by 60%, from 1,340 in 2008/2009 to 540 in 2013/2014, and expenditure on this service fell from £1.32 million to £1.05 million over the period. Meanwhile, the number using day care services fell by 40%, from 2,195 to 1,330, with expenditure on these reducing from £9.5 million in 2008/2009 to £4.02 million in 2013/2014. By contrast, expenditure on equipment and adaptations for older people living at home rose by 25% (from £1.19 million in 2008/2009 to £1.49 million in 2013/2014), and expenditure on direct payments to older people (enabling them to recruit and direct their own support workers) increased by 96%, from £2.03 million to £3.98 million.

During the period, packages of care provided through Leeds City Council to older and disabled people living at home became more intensive. Care was delivered more frequently, or for longer periods, to people with higher levels of need. Less support was provided for a smaller number of people with lower level needs, as shown in Table 1.

Table 1.

Home care service users (numbers and percentages), 2008/2009—Leeds, UK.

Home care visits by duration of visit		2008/09	2009/10	2010/11	2011/12	2012/13	2013/14
Up to 2 hours	No.	815	545	510	485	360	245
	%	18.6	14.4	12.3	12.8	12.8	6.4
Over 2 hours and up to 5 hours	No.	1,145	850	870	730	630	515
	%	26.1	22.5	47.4	19.2	17.6	13.5
Over 5 hours and up to 10 hours	No.	1,070	985	1,115	1,135	1,040	870
	%	24.4	26.1	30.0	30.0	29.1	22.8
Over 10 hours, incl. Overnight / live-in / 24 hour	No.	1,365	1,400	1,640	1,455	1,550	2,185
	%	31.1	37.1	40.0	38.3	43.3	57.3
	No.	4,390	3,775	4,135	3,800	3,580	3,815
Total	%	100	100	100	100	100	100

Source: NASCIS (2015) Table RAP H1.

This trend was consistent with the Council's policy of providing or arranging services of this traditional kind for those with the greatest needs, which could not be met in other ways, but of addressing budget pressures by supporting “fresh alternatives to traditional social care and support services” and encouraging “flexible and innovative ways of delivering care and support” (LCC, 2012c, p. 115). The Council was explicit about the challenges it faced in meeting growing demand and demographic pressures in the context of severe budget restrictions, and its official papers indicate that these factors were regularly assessed (LCC, 2014c).

Its approach also included policies intended to modernize and diversify support for older people, by drawing increasingly on initiatives that could mobilize local communities and volunteers in support of the city's older population. Its flagship approach to achieving this goal was the city's Neighbourhood Networks of Older People initiative, which had been in development since the late 1990s. By 2008, this network was contributing an estimated £800,000 worth of volunteer time, and the initial public funds invested in it had been more than repaid, as the networks had generated more than twice the amount from other sources (LCC, n.d.).

By 2009/2010, Leeds' neighborhood networks comprised a volunteer workforce of 5,948 people, providing individual support to over 17,000 older residents. Their activities were focused on befriending services (to 2,697 older people), advocacy (to 2,692 older people), gardening services (to 3,332 older people), and other support, including shopping (LCC, n.d.). In 2010, a review of the procurement and commissioning process for these schemes reported on how the initiative had moved from its original grant-aided to new contractual, service delivery arrangements. The shift arose, in part, from expectations of the (national) Department of Health, which resourced the NHS share of its funding (alongside the Council's contribution) and favored this approach (LCC, 2010).

Leeds' neighborhood networks, “largely run and staffed by older people,” numbered 37 by 2013/2014; the City Council described them as “[o]ne of the great success stories of social care in this city,” and as “inventive and very skilled at finding solutions closely tailored to the needs of the communities where they work” (LCC, 2013a). By this time, they were supported by 5-year core funding of £2 million per annum, an investment made possible, according to one report, by “tough decisions by the council to sell council-owned residential care homes” (MacNeil & Hunter, 2014, p. 37). A further £300,000 of additional recurrent funding, and an 8-year commitment to continue support, was announced in 2013 (LCC, 2013a).

Support for Older People through the Leeds Telecare Service

Leeds City Council's telecare service began some 30 years ago as a community alarm service. It was significantly expanded and developed in the late 2000s, using the central government's Preventative Telecare Grant (available from 2006–2008) and by 2009 had become a mainstream service funded through Leeds City Council's Adult Social Care budget.

By 2011, when the AKTIVE study began, the Leeds Telecare Service was free to older people living at home, and had staff that sourced telecare equipment, trained Council staff to assess older people's needs for telecare, and installed and maintained the telecare equipment. Older people with relevant needs could access telecare through a social worker, health professional, or voluntary agency or could refer themselves directly as pendant alarm users. They were neither means-tested nor charged for the service. As part of the telecare needs assessment and implementation process, they were asked to give details of two friends or relatives who could be contacted and were willing to attend to them, if needed, a process that had the potential to strengthen supportive and caring relationships in local communities (Yeandle, 2014b). As part of its telecare support arrangements, the Council also operated a response center (Care Ring), which monitored all telecare calls and alerts and provided a back-up emergency response for any service users who lacked a nearby relative, neighbor, or friend, or whose named contacts could not be reached at the time of an alert.

In 2012/2013, despite the many financial pressures it faced, Leeds City Council released an additional £1m of its capital funds to develop its Telecare Service, seeing it as a means of securing economies elsewhere in years to come. Its rationale included its view that telecare 1) enhanced the safety of frail older people living at home; 2) was effective in providing peace of mind for older people living alone and for their families; and 3) offered a cost-efficient way of helping some people remain in their own homes (in some cases with other support as well), rather than move into (more expensive) supported housing for older people or to a residential care home.

As a consequence of this approach, and in contrast to the declining numbers using council-supported home and day care, the number of people in Leeds receiving telecare support grew; by 2012/2013, it exceeded the number receiving home care. Official reports indicate that between April 2010 and January 2012, the number of telecare users in Leeds rose by 103%, from 2,069 to 4,203 (LCC, 2012b). Data for the year 2011–2012 alone show Leeds Telecare Service spent £533,565 on telecare equipment, made almost 2,000 new telecare installations, and had a total of 4,381 registered users (LCC, 2012a), while the Council's (then) separate Care Ring service had an estimated additional 10,000 clients with a single pendant alarm device (but no other telecare equipment).

Alongside this additional investment, and following a review of all its charging policies in 2012/2013, Leeds City Council decided to introduce means-tested charges for telecare (from 2014). Evidence used to inform this decision included estimates of what users of the service would pay. The Council expected that 9,000 of its 10,000 clients with a simple pendant alarm would be required to pay £2.50 per week; 1,500 of its 4,000 clients with telecare peripheral monitors would be charged up to £3 per week; 60 of its 100 clients with GPS tracking devices would pay up to £9 per week; and 300 of its 1,000 users of the telecare mobile response service (for those without nominated responders) would pay £3 per week (LCC, 2013b). It consulted widely on these proposals, receiving responses from over 3,000 telecare users. After considering the issues raised, some of the proposed charges were reduced, and some additional exemptions from charges were agreed upon; however the imposition of charges resulted in some users returning their equipment (LCC, 2013b, Appendix 3).

Support for Carers

The contribution made by unpaid carers has been recognized in the English system of care and support for many years, in large part due to the activities of voluntary sector carer organizations, which since the mid-1960s have sought to inform debate and mobilize support for policy change on behalf of those they represent (Cook, 2007). This activity has raised awareness of carer support needs in England and led to the development of three main types of publicly funded support for carers: modest financial assistance (Carer's Allowance, a national cash welfare benefit administered outside local authority systems, available to people with low personal earned income who care for at least 35 hours per week for a person receiving certain disability benefits); local services designed to support carers (provided by some local authorities, including Leeds City Council, often following a Carer's Assessment); and legislated, albeit limited, employment rights, developed since 1999 through various Acts of Parliament (Yeandle et al., 2013). In the period 2008–2013, this legislation entitled most carers in paid employment to a short period of (unpaid) time off for a family emergency, gave them the right to request a flexible working arrangement (which their employer was obliged to consider and could only refuse by giving a “business reason” for doing so), and (irrespective of their age or employment status) required their local authority to offer a formal assessment of their needs (a carer's assessment) if they provided substantial and regular care.

In line with some other English local authorities, by 2008, Leeds City Council already had well-established working relationships with local voluntary organizations through which local support services for carers had been developed. Since 1999, all English local authorities have been supported in this by modest central government funding (allocated through the Department of Health), known as a “Carer's Grant” (Fry, Price, & Yeandle, 2009). The following paragraphs focus on local support for carers in Leeds resourced by or through Leeds City Council.

Leeds City Council launched its first carers' strategy for the city in 1995 and, in the same year, helped to establish a Leeds Carers' Centre, operated by Carers Leeds, which still exists. Carers Leeds has received a range of financial support (covering some of its costs) from both the city council and relevant local National Health Service organizations over most of the past 20 years. During this time, the Council has commissioned a variety of other support services for carers. These focused initially on carer's breaks and respite support, and were developed with the support of a multiagency Carers Strategy Implementation Group (formed in 1995). Other flexible support services were added in later years (Yeandle et al., 2007a).

Despite these efforts, data from the national census in 2011 suggest there is considerable unmet need among carers in Leeds. Carer needs are now generally quite well understood. They are more likely than other residents of similar age to be in poor health or to have a health condition that affects their day-to-day activities (Carers UK, 2014). Many are people of working age; in 2011, 71% of carers in Leeds were aged 25 to 64 (ONS, 2013). Carers in this age group often give up work to care (Yeandle, Bennett, Buckner, Fry, & Price, 2007b; Fry, Singleton, Yeandle, & Buckner, 2011; Carers UK, 2014) and frequently suffer significant financial hardship as a result. However, many combine their unpaid care with paid work, some experiencing considerable strain in doing so (Carers in Employment Task & Finish Group, 2013). In 2011, Leeds had 38,398 carers combining paid work and unpaid care. It also had many older carers (aged over 65), some of whom were of advanced age and in poor health themselves, many caring for other older people with care needs. Among carers, the poorest and most disadvantaged are found among those receiving the state benefit Carer's Allowance. In Leeds, their number rose by 49% between 1999 and 2011, from 3,340 to 4,990 (Fry et al., 2011), and by 2012 (latest data) it had reached 6,250 (DWP, 2012).

Leeds City Council's data on carers in touch with its Adults and Children's Services show that in 2010–11, just 3,952 Leeds carers were known to the council; of these, 2,565 had their needs formally assessed, 625 received support from the Council in the form of a one-off payment (LCC, 2011), and in May 2011, 410 had a direct payment in their own right to help them meet their own needs as a carer (HSCIC, 2011). The Council readily acknowledges that it does not connect with all carers, commenting:

Even with a broad and comprehensive range of commissioned carer support services developed over the last 15 years, less than 10% of the total carers are in touch with Adult Social Care. In 2011 there were 25,914 people caring for over 19 hours per week but Adult Social Care are delivering less than 4,000 carers assessments each year. (LCC, 2014b)

To guide the development of local support and services for carers, the City Council works with partner organizations to develop a regularly updated carers' strategy. The main carer organizations offering support to carers in 2008–2013 were Carers Leeds; the Mental Health Carers Support Service; the Dementia Carers Support Service; and Older Carers of People with Learning Disabilities. The national charity Carers UK also had an active local branch in Leeds during this period, while Alzheimer's Leeds and Age UK Leeds provided services for carers age 65 or older.

In these years, their activities were guided by the strategy for 2009–2012, based on “consultation and listening events with carers” (LCC, 2009, p. 5; The Leeds Initiative, n.d.). They included a carers' charter, a statement of aims, the implementation strategy led by the Carers' Strategy Implementation Group (cochaired by representatives of Leeds City Council's Adult Social Care department and by NHS Leeds), and statements of intent set out by Leeds City Council, NHS Leeds, and the Leeds Teaching Hospitals Trust. The strategy aimed to establish a carers' hub, enabling all carers to participate in service planning consultations; use new central government funding to develop alternative care to support carers in emergency situations; commission services appropriate for those with specific language / cultural needs, so their carers could access short breaks; improve guidance on home adaptations to help carers care safely at home; and require home-based breaks providers to give families advance notice of which workers would attend them. The Council provided some funding to help these organizations deliver specific carer services and collaborated in running a carers' emergency plan scheme, which could replace the support of a family carer for up to 48 hours in an unforeseen situation.

While it is not possible to assess how many carers accessed support in this way, it is likely many who did so were carers who did not access the Council's services directly. Leeds City Council's website consistently emphasizes its commitment to improving services for carers, and the Council is active in implementing the Carer's Charter featured in the local strategy and in responding to developments in national legislation affecting carers, under the leadership of a senior officer with specific responsibility for carers.

Discussion and Conclusions

Leeds City Council's Strategy and Approach

Demographic pressures in Leeds present ongoing challenges for service planning in the city, which has been preparing for and responding to these for well over a decade. As early as 2004, projections indicated that Leeds' population of people aged 85 and older was likely to rise by 48% (an extra 6,300 people) between 2001 and 2021 (Yeandle et al., 2007a), and (as noted earlier) the number of residents aged 85 and older rose by 9% between 2001 and 2011. Recognizing the implications of this demographic change, Leeds City Council's Adult Social Care “Market Position Statement” in 2012 noted that, “given the prevalence of dementia, other illnesses and long-term conditions among this age group … more people are likely to require care and support” (LCC, 2012a, p. 13). It explained that its service planning was informed by its awareness that in the city 38,491 people aged 65 and older were “unable to undertake at least one self-care activity” in 2010, and 47,000 were “unable to complete at least one domestic task” (LCC, 2012a, p. 13).

The Council also recognized that increased longevity was reshaping the age structure of its population, changing it to one in which there were fewer people of working age and more older people experiencing frailty and poor health. This altered age structure was simultaneously increasing demand for care and reducing younger people's ability to care for older people, whether in a paid or unpaid capacity.

Despite the national policy developments already noted and three National Carers' Strategies (in 1999, 2008, and 2010), which incrementally increased central government support for carers and contributed some national funds to develop local carer services (HMG, 1999; 2008; 2010; Fry et al., 2009), Leeds City Council, like other English local authorities, has resourced most carer support from its own budget. It allocated these resources, despite other pressures, because it recognized carers as the backbone of the city's care and support system.

In 2010, in its first “Commissioning Prospectus for Adult Social Care,” the Council set out its perspective and expectations about future support for older people, carers, and others within its remit, emphasizing that “successful commissioning depends on robust partnerships.” In 2012, it introduced a new partnership approach to commissioning care services (LCC, 2012a), pointing out that the public policy context “to which the market will have to respond” meant adult social care was “set to change radically in the coming years” (p. 4). In response to central government guidance, a new offer for adult social care was being developed. This would shift the “balance of power in … decision-making and the control of resources away from statutory authorities” (LCC, 2012c, p. 9), a change, it explained, which responded to central guidance “aimed at introducing engagement and co-production as key elements in the process of producing health and social care.”

Three main developments were indicated: replacing directly provided services with a “coordinating role” in providing information and advice to “people and their carers” about options available on how to produce “the best outcomes for them”; responsibility for “stimulating and shaping the market for personal care, social care and related housing support services,” through new partnerships, the provision of market intelligence and a new analysis and forecasting role; and a lead role in promoting the health and wellbeing of citizens, which would include inspiring, overseeing and incentivizing care providers to deliver “better outcomes for service users” (LCC, 2012a, p. 10). The future emphasis, it explained, would be on prevention, personalization, partnerships, and productivity. Thus, in response to the “new public policy promoting localism,” the local authority's past approach of developing services for “individuals or whole communities” would change, with some future services commissioned for “neighbourhoods and communities of interest.” Key challenges identified were to reduce demand (via “prevention”); to divert demand (“away from specialist social care … into the mainstream”); and to improve demand management (using “evidence-based,” “timely,” and “smarter” solutions, using new technologies and avoiding “institutional options”; LCC, 2012a, p. 11).

This approach, consistent with the ideological slant indicated by the Conservative-led Government's commitment to developing the Big Society (Alcock, 2010) and reiterated in a subsequent City Council Adult Social Care Market Position Statement (LCC, 2014b), developed well-established trends in how home care is delivered.

Considerable change in the period 2008–2013 was evident in the role of the voluntary sector in Leeds, with voluntary sector organizations working closely with the City Council to deliver services and support to older people and secure funding from other sources to develop services. The motivation for this approach arose both from the funding cuts already outlined, and from a developing commitment to new ways of working, consistent with the localism approach. As the city council put it in a comment on “horizon scanning” in 2014:

A new emphasis on innovation and flexibility will require a reciprocal response from commissioners which loosens the bureaucracy of procurement and rewards innovation. … New forms of care packages will need to be developed to drive down transactional costs and allow social workers to focus on professional interventions with service users.… There will be more support to volunteering and other community infrastructures to enable local people to help themselves. … This shift in focus … will require new information and intelligence systems as the local authority becomes more of a community enabler, rather than organizer or provider of services. This enabler role will emerge in all aspects of the council's business. (LCC, 2014b, p. 29)

An example of such a development was the emergence of the Leeds Older People's Forum (LOPF), an independent organization which promotes the well-being of all older people in Leeds and aims to give them a voice in shaping decision making in the city, to represent their views and highlight their needs and aspirations, working collaboratively with relevant third sector organizations in the city. Established in 1994, by 2014 it had grown to a citywide membership of over 100 voluntary sector organizations, including the city's neighborhood network schemes discussed earlier in this article. Between 2012 and 2014, LOPF worked with a core partnership of 18 organizations in the city to develop and secure a collaborative bid for £6 million of (national) Big Lottery funding via the Fulfilling Lives: Ageing Better program. The plan is to use this money to establish services and activities to combat loneliness and social isolation among older people.

Assessment in Terms of Social Quality

The exploration of support for older people and carers in Leeds in this article has indicated that the years 2008–2013 brought significant changes for older people in the city in terms of their access to services, the kinds of services they receive, how support is organized and supplied, and the charges made to those receiving them. These can be summarized as a situation in which:

1. Home care support arranged through Leeds City Council is now provided to far fewer older people and is substantially outsourced. Growing numbers of home care clients make copayments or pay for the service they receive, and fewer older people, with greater needs, are able to obtain these services through the local authority.

2. There are considerably more older people using technology to support them to live independently at home, as evidenced in the expansion of the Leeds Telecare Service, although some now have to pay for this formerly free service.

3. More older people are using funds Leeds City Council makes available to support their needs to purchase care from a personal assistant.

4. The city successfully introduced a new “reablement” service, providing new support to older people discharged from hospital and enabling many to regain their prior ability to cope without additional support.

5. Volunteer-based schemes, some constituted as “social enterprises,” delivered primarily by older people themselves, expanded and provided support to more older residents than were receiving home care and day care support.

These changes indicate that considerable restructuring has already taken place in the landscape of support for older people. Leeds had a range of support schemes and processes in place on which it could build, well before the austerity measures announced in 2010 took effect. These plans gave energy to council officials, local people, and voluntary organizations as they addressed the challenges imposed by the significant budget pressures they faced.

Among carers, national data show people in the 45–64 age group are increasingly taking on unpaid care responsibilities alongside paid work (Buckner & Yeandle, 2014). This challenge has led to some progress in work-care reconciliation in social care support and employment policies, to which some local employers have responded, and local carer organizations have given increasing priority to support for “working carers.” Data on Leeds City Council's support show this remains limited, however. Data on support for carers following individual assessment of their needs show that, while it performs well (compared with all English authorities) in supporting carers aged 65–74 and aged 75 and older, in 2013–2014, it met the needs of fewer working age carers than the national average (HSCIC, 2014c). Implementation of a new Care Act, passed into law in 2014, began in April 2015. The Act gives English local authorities new responsibilities. The well-established involvement of local carer organizations in the development and evolution of the Leeds Carers Strategy seems to signal that a multiagency approach to providing and expanding carer support is likely to continue.

In general, and in relation to the aspects of social quality indicated earlier in this article, there is evidence that Leeds City Council has taken steps to encourage and support a “bottom-up approach,” committing resources to this and paying attention to the experiences of its citizens. In its efforts to mitigate rising inequalities and risks, it has also paid close attention to “cost-efficiency” and worked to develop local “coalitions and solidarities.”

Some new opportunities have been created to consult citizens, including older people, and to engage them in service planning and in making choices about how services should be shaped in the future. In debating service changes, the awareness of some citizens has been raised, and some older people have found increased opportunities to raise their voice as the infrastructure of local services shifts. Some would claim choice has been extended through recent service developments; choice has certainly been an objective of some service redesign and restructuring.

At the same time, central government, which retains a high degree of centralized power in this policy area, has signaled its view that the direction of change, nationally and locally, should be toward “technology-enabled care services,” suggesting a continued commitment to bringing together health, social care, and voluntary and private sector arrangements for older people's services. In the future, this approach will be underpinned by joint budgeting, but will remain subject to the constrained resource environment described in this article (NHS Commissioning Assembly, 2015).

Phase 1 of the Care Act 2014 was implemented in April 2015; it gives English local authorities new statutory duties, which include providing services to support the assessed needs of individual carers who are eligible. They must also focus on prevention, guided by the principle of wellbeing; provide information and advice; and address the “market shaping” of social care provision. Implementation of phase 2 (a cap on care costs and the duty to arrange care on request for self-funders) has been delayed from 2016 until 2020 (Parliamentary Statement, 2015).

How far choice and quality support can be a reality for more than a few, or for those lacking the private resources to make their own arrangements in the service market which is emerging, is likely to be contested politically. However, many commentators believe that, even where local authorities are responding as Leeds has done, rising socioeconomic inequality in the United Kingdom makes it impossible for real choice about support—adequate to meet needs in later life—to be available for all under current public policies and resource constraints.

The evidence considered in this study of support for older people in Leeds includes published statistics relevant to social care and data collected in four studies relevant to support for older people and carers in Leeds. Together these provide detailed insights into the processes and changes described. A limitation of the approach is that the focus on how Leeds responded to national changes in the financing and governance of local social care was developed after some of the studies were completed and was addressed explicitly in only one of the studies discussed (the FLOWS study).

Combining relevant evidence from these sources has been valuable in highlighting several issues relevant to policy making and practice at the national and local level, however. As the article indicates, there are major constraints on “vertical subsidiarity” in Leeds (and other English cities), with the local authority's tax-raising powers and autonomy in making decisions about older people's services and support heavily influenced by national law and central government policy directives, albeit tempered by local processes that involve horizontal subsidiarity: partnerships, consultation mechanisms, and an emphasis on some aspects of “localism.” (The latter are exemplified by the transfer of some powers and responsibilities to other organizations in the city and to local communities.) Evidence from Leeds suggests that when strategically implemented, these approaches can be effective in developing some new forms of support for older people and carers.

This article has also highlighted the ongoing trend in England toward greater horizontal subsidiarity, initially set in train by national legislation in 1990, which required local authorities to develop a mixed economy of care and has led to growing outsourcing and privatization of older people's services. The consequences of this move have been considerable diversification in service provision and in charges to service users. Detailed local data on this are scant, but national analysis of the existing evidence base shows significant growth in older people self-funding the services they require and predicts significant future unmet need (Burchardt, Obolenskaya, & Vizard, 2015).

Between 2008 and 2013, cuts in local authority budgets were a very significant pressure in Leeds. The financial restraint imposed by the central government was implemented locally through detailed expenditure planning based on a degree of local discretion and considerable consultation with other agencies and local citizens. Nevertheless, as current national expenditure plans indicate significant additional cutbacks in the public resources available to support the needs of older people and carers in future years, it seems likely that, irrespective of the best endeavors of the local community, unmet need among older people and carers is set to increase. It is likely this problem will be challenging for social care practitioners and service users alike. Further research is needed into how these continuing developments affect support for older people and carers at the local level. New comparative studies of the way support is being redesigned, and its longer-term impact on older people, carers, and service providers (including volunteers and paid staff), will be needed to assess fully the scale, impact, common features, and variations of reconfigured local authority arrangements as communities respond to post-2008 financial constraints and to alterations in central-local governance.

Funding

The research referred to was funded by awards from Carers UK (CES study); the Department of Health (Regional Profiles); the EU (FLOWS study, directed at the Aalborg University by Prof. Per Jensen); and the UK Technology Strategy Board and Economic and Social Research Council (ESRC) (AKTIVE). The author is grateful for this financial support without which the studies would not have been possible.