This is the National Care Forum’s (NCF) response to the House of Lords Adult Social Care Committee inquiry on ‘Lifting the veil: Removing the invisibility of adult social care’. Our response draws upon a number of case studies from our members as well as intelligence from our regular calls and forums with members. We appreciate this opportunity to share our views, and are more than happy to produce any further information or oral evidence that might be required by the committee.
NCF brings together over 160 of the UK’s leading social care organisations, representing large numbers of care providers, offering thousands of services across the country, which are not-for-profit and always at the heart of community provision. Collectively, these organisations deliver more than £2.3 billion of social care support to more than 222,000 people in over 8,200 settings. The NCF membership body collectively employs more than 117,000 colleagues.
We agree with the premise that social care is invisible and we observe that it is invisible in a number of different ways, largely caused by how confusing and complicated the system is for everyone involved. There are a series of ‘disconnects’ in the adult social care system in England between different stakeholders, such as between central and local government, between DHSC and DLUHC, between commissioners and providers, and between those accessing care and support and their families on one hand, and the commissioners and coordinators of care on the other. Each of those ‘disconnects’ create points of tension for different stakeholders to navigate and indeed different stakeholders feel invisible at different points.
For the general public, social care is ‘fuzzy’ and not as well defined as the NHS which has a very clear identity, and principle of being free at the point of use. Adult social care feels hidden in comparison until you or a loved one needs it and then has to grapple with navigating local systems of assessments, eligibility criteria, care options and how to pay for them. For parliamentarians and policy makers, the complexity of the system has led to an overly simplistic narrative about what social care is and how to ‘fix it’, which adds to the invisibility many feel because they are absent from the narrative. This has too often seen social care synonymous with care homes for older adults who are frail, and individuals facing catastrophic care costs who are forced to sell their homes to pay the costs of care. This is certainly the experience of many, but social care is so much more diverse than this; it is not, as is often implied, a service to manage someone’s mental and physical decline or a burden on the state’s finances, rather it should be seen as a public service that enables people to live their lives to the full, in the communities that matter to them, in the way they want, despite their health and care needs. It is also much more than simply an appendage of a Local Authority or the handmaiden to the NHS.
Social care does not feel an equal partner to the NHS when it comes to policy making and funding, as well as the general public consciousness. One of the clearest examples to this is the approach to workforce planning. Adult social care is currently experiencing its worst workforce crisis, and yet, the focus is on NHS waiting lists which are in part caused by this crisis.
The workforce crisis in social care has been growing for a number of years and this has been systematically illustrated by the annual workforce reports from Skills for Care. In October 2021, Skills for Care’s annual state of the adult social care sector and workforce report stated that there were 105,000 vacancies in social care while the number of job posts available had decreased over the previous 12 months. This means that while demand is going up for social care, capacity in the system is shrinking. As of April 2022, the vacancy rate in social care stood at 10.3% (it was 6% in March 2021), rising to 18.3% for nurses in social care.
The result of all this is growing unmet need and a greater burden placed on both social care workers and unpaid carers – these groups seem to be invisible to policymakers. According to a survey by ADASS, more than 500,000 people are now waiting for assessments, reviews, and/or care support to begin. Making the focus of resources and policymaking on the NHS elective recovery plans, without addressing care and support at home and in the wider community, means people’s care needs increase, increasing burden being placed on unpaid and paid carers, and inevitably, more needing higher levels of hospital care.
An added issue is the gendered nature of social care; too often it is assumed that female family members will pick up care needs when the state fails to do so. This also impacts perceptions of care work itself. There are quite clearly a number of gendered assumptions about the value and prestige of care work. The demography of the social care workforce (82% female) illustrates this narrative.
For people using care and support services, invisibility also comes from how difficult it is to meet eligibility criteria and access care and support. Of particular note is the difficulty for some care recipients to get their care funded due to disagreements between NHS and LA commissioners as to who is responsible. A number of our members have also flagged the invisibility of people in in-patient settings. The Transforming Care agenda was partly aimed at getting people out of long-term settings and back into communities. People in these in-patient settings feel forgotten about despite our membership having the services to help.
Finally, the lack of data and academic research in social care will only serve to keep social care, and those seeking to access it, less visible to policymakers.
It is clear that we all need to change the current narrative and educate our citizens and our communities about what social care is and how it benefits society. We need a shift away from the negative narrative that currently exists to one that shows the potential for social care as enabling people and their communities. This will involve ensuring that a voice is given to those who access care and support, their carers and the workforce. Social care matters to us all and some point, the majority of us will need it.
From the perspective of our members, a focus on the workforce is a key element in resolving the invisibility of social care by reducing unmet need, enabling unpaid carers to have respite leave and enabling a more person-centred approach. There are a number of ways this can be achieved.
The Social Care Taskforce Workforce Advisory Group recommended back in the summer of 2020 that as a top priority, immediate action should be taken to improve the pay and recognition of the workforce:
(a) comparable with the NHS and equivalent sectors;
(b) fully-funded by Central Government;
(c) mandatory on employers and commissioners of services
Neither of those recommendations have been met by the government – the second one in particular is essential if we are to make sure that care workers have the pay, terms and conditions that their skills and value merit. Great care needs great people and better pay, terms and conditions are critical to the future sustainability of care and support.
In addition to the above, we think the following are also needed:
- A fully funded registration scheme for social care workers in England like the other parts of the UK
- An equivalent to the NHS Workforce Survey for social care staff
- A social care workforce plan that considers the future demand and demographics of wider society
- Joined-up workforce planning, learning and development with the NHS
Another key aspect of the narrative that needs to change is the perception of adult social care as an adjunct to the NHS. Social care must be publicly recognised as an equal partner to the NHS, as two sides of the same coin seeking to deliver the best care and support for people, with people. Some of the recommendations above would help. From our perspective, there is much that that the NHS leadership and system as a whole can learn from adult social care providers about delivering great person-centred care. The new Integrated Care System structures offer a fantastic opportunity to bring the social cre provider voice to heart of strategic, joined up health and care decision making and planning. Without this voice, there is a risk that nothing will change.
Finally, despite receiving a lot of focus in the wider narrative, older adults are not often engaged in co-production or listened to when it comes to their care and support. A number of our members are calling for an Older People’s Commissioner for England to help amplify their voice – to champion, celebrate and protect our ageing population – on a whole range of issues, not-least in terms of access to suitable housing and care services.
Adult social care should enable and empower people to live their lives to the full despite their circumstances. It should support them to do what they want to do, when they want to do it and live surrounded by their community as far as this is possible. It should promote independence, holistic wellbeing and give individuals, their family and carers, a real involvement in their care and support. We do not believe this purpose should change depending on age. How it is practically enacted might look different but the spirit should remain the same. For instance, for working age people in receipt of care, social care can empower them to enter or re-enter the workplace in a way someone in their 80s might not be looking to do or be able to do. It is about care tailored to that person.
Social Care Future puts it like this:
‘We all want to live in the place we call home with the people and things we love, in communities where we look out for one another, doing things that matter to us’
Invisibility in this context means that people aren’t properly listened to when it comes to understanding what they want and need from care and support services or when they are unable to access services due to the pressures we’ve listed above: workforce shortages, growing unmet need putting pressure on wider system, health and LA commissioners unable to co-produce services and huge issues with funding and resources to support commissioning and choice. Co-production must be at the centre of good care and support. Systems need to have processes to enable this. Sadly, the Health and Care Act 2022 missed the opportunity to create mechanisms in the Integrated Care Systems for people who access social care services to have their voice heard. There is a mechanism for ‘patients’ of the NHS through Healthwatch but not everyone who accesses social care services needs NHS support or would class themselves as a ‘patient’ – this is a very unfortunate oversight. Case studies from two of our members, Active Prospects and Look Ahead, illustrate what good care and support can look like, and what it needs to look like on a wider scale in the future:
One of the key challenges facing people who draw on care and support and their carers is the pressure that changing demographics are placing on the health and care system at the same time as resourcing and funding not keeping up with demand.
Skills for Care estimates that by 2035, we will need a 29% increase in the number of adult social care jobs. At the same time, the government’s own evidence review says that the number of over 65s is projected to increase by 43% (from 10.2 million to 14.5 million) and the number of adults aged 85 and over is projected to increase by 77% (from 1.4 million to 2.4 million) between 2018 and 2040. By comparison, the 20 to 64 population is only projected to grow by 3%. Currently the workforce is shrinking, as illustrated earlier in this submission. The age profile of the workforce is also skewed towards older age bands with relatively few under 25s. The result will be that the burden will fall on unpaid carers and this of course overlooks the fact that increasingly people are ageing without children to support them. Workforce planning is urgently needed.
Any workforce planning must also take into account an increasingly diverse population and reflect that. It must also be prepared for medical advances which allow people with complex needs to live longer.
There are also a number of other assumptions in the policy world which are not being addressed. How will people pay for their care needs if the state is unable to meet them or makes eligibility criteria stricter? An ongoing assumption in the policy world – even after reforms – is that individuals have housing wealth to fall back on to fund their care. This is increasingly not the case and is certainly not the case for many working age people. Home ownership is falling in younger age groups. If access to social care continues to be based upon being able to fall back upon housing wealth, we are in trouble.
Other respondents will be better placed to answer the questions posed relating to unpaid carers, but from a not-for-profit providers’ perspective, families and unpaid carers contribute a massive amount of support to people. This continues even after someone receives formal care – informal carers will always remain essential and need to be valued more by our society. We note with disappointment that the Queen’s Speech was silent on introducing legislation that would have granted unpaid carers the rights for a form of respite leave. We would add that you need a social care system that enables unpaid carer leave – that will require a workforce plan, greater recruitment and retention and a real commitment to listen to and work alongside unpaid carers and those they support.
27 May 2022