Written evidence submitted by National Care Forum
The National Care Forum – Who we are and Summary
The National Care Forum brings together over 165 of the UK’s leading social care organisations, 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 230,000 people. The NCF membership body collectively employs more than 114,000 colleagues.
Our submission underlines the importance of the meaningful involvement of adult social care and support providers, and those using their services, in Integrated Care Systems (ICS) if they are to achieve their health and wellbeing outcomes. Good social care and support is preventative in nature, allowing people to retain their independence for longer, doing the things they want to do, living in and contributing to their communities and working. It does far more than hospital discharge. Poor health and wellbeing cannot be tackled by NHS services alone, as this submission will outline below. ICSs are in danger of entrenching an acute health-focused view of the world, rather than promoting the culture of partnership that is needed.
Since the introduction of the Integration and Innovation ICS white paper in February 2021 and the Health and Care Bill (now Act) later that year, we have been working to try and ensure that the voice of adult social care and support providers, and those that use their services, are meaningfully included in the structures and culture of the new Integrated Care Systems. Central to this work has been convincing DHSC and NHSE that they need to be thinking about formal structures for social care representation (in the absence of any prescription in legislation) and guidance to encourage systems to meaningfully include social care and support providers who, up to this point, have felt shut out of the development of and engagement in the new systems. Alongside the work of the wider Care Provider Alliance, this approach has borne some fruit in a number of pieces of guidance published at the end of July and start of August which hopefully signals a shift:
However, there is a gap between this guidance and local practice. At present, at the local level, the structural arrangements laid out in the Health and Care Act in combination with a health-dominated culture, mean that the ICSs are currently far too acute health focused, with all other areas seen through that lens. Discharge from hospital is a good example – adult social care is being seen solely through the lens of discharge and winter pressures, rather than a service in its own right that can promote prevention and community-based care. The challenge, as always, will be implementation and culture change within very NHS-dominated systems towards partnership working. In the words of the adult social care principles document linked above, “adult social care providers are critical partners in planning, delivering, and improving health and wellbeing outcomes”. Without social care and support providers fully embedded in ICSs, they will fail in their mission. As it stands, providers in our membership are unable to engage at the system level because system leaders regard them as simply commissioned services, rather than key strategic partners who can help co-design and commission services.
3. Integrated Care Partnerships and Integrated Care Boards
We have the following key messages and asks of policymakers and local system leaders. These have been influenced by our involvement with Public Policy Projects’ ICS Futures roundtables and report.
1.1. Social care and support has a significant role in unlocking the potential of people to engage with their communities and do the things they love. Social care, at its best, is a mechanism to tackle health and socio-economic inequalities, a net contributor to local economies (£51.5bn in 2021/22) and has the potential to unlock growth in all areas of the country if invested in and treated as a key piece of national infrastructure, interlinked to other policy areas such as housing, mental health and physical health, among others – ICSs can enable this.
1.2. There are a diversity of social care and support organisations throughout the country, not just CQC regulated services, and they are part of a wider ecosystem which can be brought together by ICSs, to include housing, mental health services and VCSEs. Social care providers are anchor institutions in their local areas that use their assets and resources to benefit the communities around them. Care and support services are rooted in their local communities, even more so for those which are not-for-profit and have a tradition of values, and local connection and mission. These providers generate spending which remains within the same community in which they exist. This spending in turn supports a wide-range of local businesses and communities. ICSs have the opportunity to harness this, as well as the insights such organisations have about local health and care needs.
1.3. Good social care and support is preventative in nature, allowing people to retain their independence for longer, doing the things they want to do, living in and contributing to their communities and working. Poor health and wellbeing is a leading reason for economic inactivity and low productivity in our society. By not investing in measures to improve health and wellbeing, such as social care and support, we’re ignoring one of the key drivers of not only economic growth but also wider societal cohesion and wellbeing. Furthermore, the social care workforce itself is predominately made up of women, as are unpaid carers. Investment to increase workforce pay, terms and conditions would in itself begin to deal with some socio-economic inequalities and this in turn could expand the workforce and allow many unpaid carers to return to the wider workforce.
1.4. In short, local system leaders have, in social care, a very powerful tool to deal with some of the determinants of health and wellbeing. Healthcare alone, particularly acute healthcare, simply cannot meet the goals of the Integrated Care Systems. Local system leaders and policy makers need to work with local social care providers to meet their goals. There needs to be a recognition that good social care and support is just as important as healthcare interventions.
1.5. The parity of esteem between social care and NHS care should be enshrined by legislation to ensure that policymakers always have both in mind with guaranteed equitable access to, and provision for, social care services.
2.1. The potential of social care and support is being constrained by consistent underfunding and a lack of workforce planning. The most recent annual report from Skills for Care on the state of the adult social care sector and workforce in England has revealed that there are now 165,000 vacancies in the sector and, more significantly, a decrease in the workforce of around 3% (50,000 people) from the previous year.
2.2. Demand for services is growing. According to Carers UK there are 6.5 million unpaid carers in the UK and a recent survey carried out by ADASS found that over half a million people in England were waiting for care assessments, reviews and/or care and support to begin.
2.3. At the same time, the social care workforce is shrinking due to recruitment and retention issues directly linked to low pay, terms and conditions and the lack of workforce planning and career structures. Care workers themselves were in a precarious position before the pandemic, with 1 in 5 residential care workers living in poverty according to the Health Foundation. Ultimately this impacts on those who draw on care and support, and their families.
2.4. A range of reports produced by the Health and Social Care committee illustrate the need for an additional £7bn a year as a starting point for social care reform and a long-term, sustainable strategy which includes pay progression on par with the NHS, professional development, training, and career pathways.
2.5. During the debates surrounding the Health and Care Bill, we and others fought to introduce an amendment which would have committed the government to publish independently verified assessments on current and future workforce numbers needed for health and social care, as a means to force the issue on workforce planning.
2.6. In the absence of a national adult social care workforce plan, ICBs should consider implementing system-level, joined-up, workforce planning across ICSs to enable comprehensive integrated care delivery. This should ensure that commissioners pay providers enough to ensure pay for social care and support workers matches equivalent roles in the NHS.
3.1. Local integrated health and care systems must ensure meaningful partnership between health and care if they are to meet the care and support needs of their local populations. The new Integrated Care Boards and Integrated Care Partnerships will be an important part of the landscape for social care in the years ahead in enabling this. It is essential the voice of those that use care and support and those that provide it are at the top table of decision making. Simply involving Local Authority and NHS commissioners is not enough, as they cannot, alone, be the voice of social care and support and will lead to acute health dominated policymaking. As it stands, providers in our membership are unable to engage at the system level because system leaders regard them as simply commissioned services, rather than key strategic partners who can help co-design and commission services.
3.2. Future integration must ensure more consistency of approach that focuses on the needs of those receiving care and support, thinking both about those who will need care and support across their whole lives, as they move from childhood to adulthood as well as those whose needs evolve due to age or circumstance. It is currently far too easy for systems to enter crisis mode and prioritise NHS issues, such as hospital discharge, without thinking about the wider system or longer-term systemic changes that are needed. Leadership of ICBs is currently dominated by health colleagues, and a healthcare centric view of the world. Total localism without some mandated national structure seems likely to bring a postcode lottery of quality and effectiveness. Without mandating a voice for social care in local systems, it seems unlikely that it will gain it consistently across the board.
3.3. Given the challenges that the adult social care sector continues to face in engaging with their ICSs, our view is that pure permissiveness for ICSs presents a very real risk of little actual change in culture, thinking and strategic approach. This means that there is a great chance that we will miss the opportunity that the ICSs offer to do things differently.
3.4. As the recent guidance on preparing integrated care strategies says: “Integrated care partnerships should recognise that the adult social care provider landscape, in particular, contains a diverse range and type providers, many of which are small to medium-sized enterprises, that will be closely tied to the communities they serve and will have important insights to inform the integrated care strategy.”
3.5. And as the Expected ways of working between integrated care systems and adult social care providers says: “ASC providers are critical partners in planning, delivering and improving health and wellbeing outcomes. ASC providers are not just delivery partners. They should be fully engaged in the work of the ICP as strategic partners. This includes ensuring their perspectives and insights are fully represented in each ICP to achieve joined-up, person-centred and preventative care together. ASC providers can be deeply rooted in their local communities. They bring hugely valuable expertise in meeting the current and future needs of their wider communities, as well as deep insight and understanding of the people and communities they serve. Their knowledge and expertise will support the ICPs to:
3.6. Policymakers should introduce a standard national framework model for the membership of ICPs that creates a defined role to ensure the voice of people using care and a defined and funded role for local care & support provider forums, with a clear role in decision-making, governance and accountability.
3.7. Policymakers should also ensure there is an Adult Social Care Lead or someone with sufficient experience and knowledge of adult social care on the Integrated Care Board to ensure accountability and good governance, as well as correcting a tendency for systems to see everything through a healthcare lens alone.