Written evidence submitted by Care England

Care England, a registered charity, is the largest and most diverse representative body for independent adult social care (ASC) providers in England. Our members run and manage approximately 4,000 care services, amongst them single care homes, small local groups, national providers and not-for-profit voluntary organisations, as well as private associations. They provide over 120,000 beds and various services for older people, working-age adults with long-term conditions, learning disabilities and mental health needs.

Since their introduction, Care England has worked extensively with Integrated Care Systems (ICSs) and has engaged with over 70% of ICSs within England. Care England seeks to actualise the opportunity presented by ICSs; these partnerships can facilitate meaningful integration between the ASC sector and their healthcare partners. Care England’s primary objective when engaging with ICSs is to establish whether care providers will sit on the Integrated Care Partnership (ICP), and, if not, understand how they will be effectively engaged. Care England has campaigned that there must be a direct representation of ASC by either a nominated care provider or a local trade association within the ICP. LAs must not be the sole representatives of ASC.

As a critical friend to Government, Care England is committed to supporting ICSs and ensuring they succeed where previous integration attempts have not, and will do so in this evidential analysis by reflecting on each of the four core objectives distinctly.

Improve outcomes in population health and healthcare

The weakness thus far presented in ICSs is that, despite this evidence of the care sector being able to improve outcomes in population health and healthcare, the structure of the ICS is not conducive to effectively representing ASC providers and therefore giving them the voice, or influence in the systems strategy to effectively use its services. The responsibility for population health expands far beyond the NHS with the care sector having a prominent duty in healthcare, yet, there is no requirement for their inclusion in the Integrated Care Board (ICB).

This imbalance will result in ICBs repeating the historic problems of CCGs misunderstanding the needs and concerns of the care sector, whilst not recognising the benefits the sector holds in alleviating pressure on NHS services. As a result of this exclusion, the ASC sector is left to operate entirely through Place-Based-Partnerships (PBPs). Despite assurances from ICSs that policy will be driven at a Place level, it is clear that many ICSs will rely on both the ICB and the ICP for overall authority, and to make significant decisions such as the direction of the integrated care strategy, on behalf of the entire system.

To have any significant involvement in this strategy, the only option providers have is to direct representation in the ICP. Therefore, ICSs should be set up to have an inclusive ICP membership to guarantee proactive and pragmatic engagement with stakeholders operating at a local level and offering localised expertise, such as all adult social care providers, otherwise, they are doomed to repeat the same issues over LA representation that have been highlighted with the ICB.

Frimley ICS confirmed with Care England that they plan to operate an assembly-constructed ICP, where there will be no upper limit of attendees. The ICS is very mindful that they don’t want to make the ICP NHS-centric, and are working to be as expansive as possible with membership. Similarly, Herefordshire and Worcestershire ICS host an Integrated Care Partnership Assembly in conjunction with the standard ICP which acts as a platform for all stakeholders to work collaboratively, share initiatives, and also raise concerns with any previously made decisions. Finally, within Nottingham and Nottinghamshire ICS the two LAs that sit on the ICP have nominated two care providers to sit on the ICP. These initiatives allow direct representation for the care sector, thus allowing better integration of health and care.

To improve population health and healthcare outcomes, ICSs need to be organised to provide a strong interrelation between health and social care and effectively recognise the value of social care services in alleviating pressure on healthcare services driving improved population health. Care providers involved within all levels of discussions in an ICS will be better suited to contribute towards discussions and decisions that drive to improve population health. As demonstrated throughout the pandemic, there is a growing understanding of how social care services can alleviate pressure on healthcare. The discharge to assess (D2A) is designed to ease the increasing number of patients occupying hospital beds beyond the required stay. ICSs can learn from the policy and look to develop new models of care that utilise the capacity within care homes and other social care services, to support reducing the backlog and length of stay within an acute setting. As noted by NHSE, 350,000 people spend more than three weeks in acute hospital beds each year between 29 November 2021 and 3 April 2022. There were consistently above 4,000 patients in hospital who no longer met the criteria to reside within an acute setting and remained in hospital for longer than 21 days.[1] The Care Quality Commission’s (CQC) latest State of Care report further reiterates that many people are stuck in hospital longer than they need to be, due to a lack of available social care.[2]

There is capacity and demand for social care providers to support their healthcare colleagues to meet the required needs to reduce the backlog. However, for this to be achieved ICSs would need to look to address systemic challenges facing the adult social care sector, particularly revolving around workforce and funding challenges, which is reflected within the most recently published winter resilience plans that state there must ‘additional support for care homes through reducing unwarranted variation in ambulance conveyance rates[3]. ICSs need to aim at achieving a more equitable distribution of resources and parity of esteem between social care and the NHS. This is because social care is not designed solely to help alleviate the pressure on the NHS. The high-quality service delivered by independent care providers is critical to the population’s health and healthcare. However, individuals who are in desperate need to receive care will continue to face severe delays in this crucial support unless ICSs properly invest in social care to boost their workforce and capacity.

Tackle inequalities in outcomes, experience, and access

Most inequalities reflect the unfair distribution of underlying social determinants, and therefore, ICSs should be set up to fundamentally change the social environment of their area to lessen these inequalities. For the care sector, this means that ICSs must be set up to build a robust preventative agenda as they currently are not organised to target specifically the development of further inequality later in life. ICSs with a commitment to prevention and health equity need to address, with an equal focus, supporting good health, as well as treating ill health; cross-sector collaboration; and the development of proportionate national approaches to ensure health equity.

The CQC’s annual assessment of health care and social care in England highlights that ‘around half a million people [are potentially] waiting either for an ASC assessment, for care or a direct payment to begin, or for a review of their care.’ This is reflective of a currently gridlocked system catalysed by a lack of funding and workforce pressures. It also emphasises that an ageing population will have significant demand for care provision in later life. While ICSs need to intervene and improve the quality of life for individuals at an earlier stage to strengthen their independence and personal resilience, from an ASC perspective, interventions in later life should be focussed more on preventing the ‘progression’ of inequality and less on its primary prevention.

CQC’s 2021/22 State of Care report highlights the growing demand for social care, by noting that in a survey of people aged 65 and over, more than a third (37%) did not feel well-supported when using a health and/or social care service. Furthermore, around half a million people are waiting for an ASC assessment, or for care or a direct payment to begin, or for a review of their care.[4] ICSs must use this recent data to address the ever-growing demand for ASC services. Through collaboration with care providers, health inequalities can further be addressed, with an increase in the development of specialist care, such as dementia, further tackling negative experiences.

To ensure that larger providers, who operate with multiple ICSs, can deliver a consistent level of care across England, ICSs should be set up with a platform to communicate best-practice and understand the different approaches to health and care that are taking place across the country. This will enable integrated care strategies to address local priorities while keeping in line with national policy.  DHSC, NHSE and CQC are all accountable for ensuring that ICSs do not differ too greatly from one another. The single assessment framework being developed by CQC must address the issue of consistency. DHSC and NHSE must provide support and clarity on keeping in line with the national agenda. This is reflected within the National Audit Office’s (NAO) recent report, Introducing Integrated Care Systems: joining up local services to improve health outcomes, where it the importance that there is national oversight of these systems to ensure that local variance does not hinder these systems achieving their core objectives is made clear.

Enhance productivity and value for money

For ICSs to enhance productivity and value for money, they need to recognise the ASC sector’s proven capability of operating financially effectively and ensure that NHS partners work collaboratively with the independent sector to build meaningful, positive relationships and harbour pragmatic joint strategic planning. For example, The average cost for a non-elective short stay (which would only be one or two nights) at an NHS hospital is ‘£959’[5] which is a significant cost in comparison to care homes, where the average cost for a week is just ‘£704[6].

Utilising the care sector’s affordability, and voice throughout strategic planning can also help systems avoid expensive and inefficient initiatives. A recent example of this is the ‘care hotels’ initiatives, which represented both mismanagement and misuse of public funds, with prominent cases in Norfolk, where £500k was spent to care for just 36 people. Had the independent care sector been approached for their support, which they evidenced throughout the pandemic that they can offer taxpayers value for money and empower those in need of care, the NHS wouldn’t have had to rely on such a costly solution.

ICSs need to encourage NHS to use existing spare capacity in care homes would significantly reduce the cost of patient care to the NHS whilst also improving the quality of the care that the patient would receive. The DHSC has not fully capitalised on this potential, and therefore ICSs must look to take full advantage of the ASC sector’s cost-efficiency and the commitment providers have to ensure the longevity and independence of those in receipt of care. Through developing new models of care and moving towards a more community-based system, driven through Place, inflated costs, as seen through the care hotel programme, will be nullified. 

To help enhance productivity ICSs need to set up robust mechanisms to support ASC providers with the ongoing workforce crisis damaging the sector. Skills for Care reported that since October 2021, there has been an increase in vacancies by 52%, bringing the total number of vacancies in the sector to 165,000. Furthermore, the South East Care Alliance revealed that 45% of care providers in the South East were considering exiting the market, with similar trends across the nation. ASC providers are being impeded in their service delivery and productivity as they are forced to use an increased amount of both agency and bank staff to paper over the cracks caused by a vacant workforce. Systems must be set up to support the ASC sector in tackling this workforce crisis to avoid an over-reliance on agency.

Furthermore, to support ICSs to properly allow for digital integration and interoperability between health and care services and to meet the Government’s commitment of 80% of providers having a digital care record in place by 2024; systems should be set up to ensure that the ASC sector is properly involved, consulted and prepared to embrace digitalisation. An ASC system that makes the best use of digital tools and technology to deliver improved care outcomes for people will be transformational and enhance productivity and value for money entirely. To fund this goal, £25m has been awarded to each system to support the implementation of DSCRs, as well as other digital initiatives such as sensor-based falls technology. With such technologies, the care sector can provide individual personal care and support plans to their integrated healthcare partners, in real time and to a higher standard.

Interoperability between the partners is a crucial step in integration, and essential to enhance productivity and value for money as there will be significant reductions in overall administrative task time, reducing costs of work (plus other costs such as paper and printing) whilst simultaneously improving the quality of care and the amount of management and oversight for the input data and the resident overall. However, this can only be achieved when the systems are set up to give providers a choice. Furthermore, to improve the partnership and integration between health and care, ICSs must aim to include ASC providers within the remit of their shared care records. Implementing and integrating DSCRs is the first step to linking up the digital systems across health and social care. Greater strides must be made to further this cause by allowing an increase in data sharing between health and care services. Whilst GDPR checks and measures must be in place to secure an individual's data, ICSs are responsible for ensuring that the right people have access to the right data, including care workers.

With the future of health and social care revolving around digitalisation, many providers already have embraced DSCRs, with circa 50% of ASC CQC registered providers have become digital. However, their form of digitalisation will be different to their respective healthcare partners, and what the systems themselves suggest. Systems need to be set up to involve all stakeholders collaboratively to understand what digital path works for which stakeholder and support the combination of these digital systems, as opposed to enforcing one particular digital system to all stakeholders, which would typically be NHS-orientated. For digitalisation to work, providers need the desire to change. If a system requires a digital method that providers will have difficulty navigating/managing or utilising, then this desired progress will not come easy, and certainly will not enhance productivity or value for money with the additional barriers created. Thus, collaboration and choice are essential to succeed in digital transformation.


Help the NHS support broader social and economic development

For the ASC sector to help the NHS support broader social and economic development, ICSs need to give proper attentiveness to the pressures the ASC sector faces, with pragmatic solutions that will stabilise it and ensure sustainability in the decades to come. Addressing the challenges facing the sector will not only better prepare the country’s ageing population but also help with broader economic development. Currently, the care sector contributes ‘£50.3 billion to the English economy’[7] however, this will only increase when considering the projected number of people aged 65+ is set to grow exponentially between now and 2035, which will parallel the increase in demand for care. For the sector to meet this, there must be an increase of 27% (480,000 extra posts)[8] in the workforce to cope with this significant demand increase.

ICSs need to account for this and ensure sufficient collaboration and facilitate the sharing of best practices between independent and statutory organisations enabling the NHS and the care sector to work in tandem to support broader social and economic development. For the care sector, this would mean an ICS commitment to a long-term workforce strategy similar to that in the NHS, which would offer pragmatic solutions such as aligning pay and benefits in the independent sector with the NHS and local authority-run services. For example, Frimley ICS and South West London ICS developing robust workforce strategies that will offer long-term solutions to help alleviate the burdens of both recruitment and retention through several different methods.

It would also mean a dedication to developing an integrated workforce which allows for the movement of staff across the health and social care sector to build a “one workforce” to lessen some of the impacts that are facing both sectors. Examples of such an initiative can be seen in South Yorkshire ICS, that are planning to create a working passport to ease the transition of staff from either sector, as well as in Shropshire, Telford and Wrekin ICS established their own Social and Health Care Partnership Training Academy. This new ICS-designed initiative is a free programme to train, develop and expand, and allow interchangeability from healthcare roles into the social care workforce with a recognised qualification certificate awarded at the end. All ICSs must take this approach to develop a ‘one Workforce’ strategy; otherwise, parts of the sector will become less integrated, leading to disparity and limiting effective development.

Although the NHS is recognised as the largest single employer in the UK, totalling 5% of the working population[9], the care sector employs more, being responsible for 6% of total employment in the UK. ICSs must acknowledge how fundamental the care sector is to social and economic development and view the sector’s influence on the UK’s economy and employment as equal to the NHS.

October 2022

[1] Urgent and Emergency Care Daily Situation Reports 2021-22

[2] State of Care 2021/22

[3] Going further on winter resilience plans

[4] CQC State of Care 2021/22

[5] National Cost Collection: National Schedule of NHS costs - Year 2020-21 - NHS trust and NHS foundation trusts

[6] Care home fees and costs: How much do you pay?

[7] Economic value of the adult social care sector

[8] The state of the adult social care sector and workforce in England

[9] NHS Jobs: Applying Overseas