Written evidence submitted by Effective Practice, University of Birmingham, University of Bristol (ASC0033)
Social Work with Older People Research Project
Submission to the Health and Social Care Committee’s Call for Evidence on Adult Social Care Reform: The Cost of Inaction
Summary
This submission is by the Social Work with Older People research project.[1] Where social workers were able to provide input to older people, carers and families, they did promote wellbeing. However, insufficient action to reform statutory provision, funding, workforce and integration, led to issues across the system.
Overall, we saw a narrowing of focus that prioritised only the most urgent situations at any time. The response was reactive rather than proactive, leading to a range of inefficiencies. The main areas that caused issues were:
There is a direct impact on older people and on carers who would be eligible for support and do not receive this. There is a knock-on impact on carers, family, friends, neighbours and networks who have to step into the gaps in state support. This impact is emotional as well as physical.
We identified potential for improvements to wellbeing (including financial wellbeing) if action was taken in the following ways:
We identified financial costs across the system as follows:
When social work and social care operate effectively they provide an efficient way of promoting wellbeing. We identified the contribution of social care to the economy in the following areas:
Despite the positive impact social work has, the benefits of it and the costs of not having social workers is often ignored. Social work should be specifically named in policy discussions. The deployment of social workers to maximise impact on wellbeing should be part of discussions about the use of scarce resources within the social care and health system.
Too often, discussions about reform lead to inaction which perpetuates inefficiencies and waste in the system, and the harmful impact of these on older people, carers and families. When weighing up the costs and benefits of reforms the following need to be considered:
Priorities for action and investment are:
1.1 This submission is by the Social Work with Older People research project[2] undertaken by the Universities of Birmingham and Bristol with Effective Practice. The research was funded by the NIHR School for Social Care Research.
1.2 Our researchers followed 10 social workers across two local authorities between autumn 2022 and spring 2023, covering a time of acute pressure in health and social care services. The study took place in two contrasting local authority sites, a largely urban site in the Midlands and a mainly rural site in the south of England. We conducted observations and interviews with social workers, older people, carers and other professionals, and looked at records. We asked: what do social workers do; what impact do they have; and how does their context affect their work? We observed the detail of everyday social work practice, and we gathered up-to-date and comprehensive examples of social work with 17 people aged over 65.
1.3 The inquiry is looking at: reform ideas for adult social care; how far these have been implemented; and the cost of not implementing them (to individuals, the NHS, local authorities and also to the wider economy and HM Treasury, focussing not only on the financial cost, but also on the personal costs and on potential benefits that are being missed). This submission provides detailed evidence from our research of what those costs are and how they are experienced.
1.4 Social workers are recognised in statutory guidance as a key profession in adult social care[3] and older people are the largest group receiving adult social care.[4] Social workers work with the most complex needs where lack of social care reform has a high impact.[5] The research produced evidence that is in line with and illuminates the wider contextual research that we summarise in the Appendix.
For this answer, we give an overview of the inefficiencies we found, and the impact on older people, carers and families.
2.1 Where social workers were able to provide input to older people, carers and families, they did promote wellbeing, particularly though building relationships, offering reassurance and advice to navigate the system, upholding rights (including the right to stay in control over one’s life), and taking practical steps to put in place appropriate support and care. However, insufficient action to reform statutory provision, funding, workforce and integration, led to issues across the system:
We have lots of conversations with homes at the moment where they’re saying, “We’ve got beds. We’ve got a bed sitting there but we haven’t got the staff to care for the people once they’re here.” That can be really challenging. Then for people going home as well, the wait for packages of care can be quite extensive, can be quite long and a very similar situation. There is just not the capacity within the area for people to be able to go home promptly. (Hospital social worker)
2.2 Some of the impacts of these shown in the detailed examples from the research were:
Nothing materially had changed for Cynthia between the review and coming into residential care, apart from the fact that no care could be found to support her at home. That’s actually what had brought her into care. Isn’t that awful? It was that the care providers gave notice. They live in a particularly, it’s not small, just a remote village, that’s probably a good 20 minutes from any centre of population. And that’s the reason Cynthia came into care. ... I think Cynthia just epitomises the difficulties we’re facing nationally in social care at the moment, and I just felt really sad about that. ...And there have been sustained attempts by our sourcing care team to find a level of care that could be provided to Cynthia in her own home over this five-month period and that hasn’t been found. (Social worker)
We just wait, is the reality. That can be, yes, just really difficult because, actually, what should be quite a simple process of it goes to sourcing, they find a bed and off they go… Then we need to maintain our involvement, we need to give reassurance back to the family, we need to give reassurance back to the ward. Things might be being updated, somebody might become unwell again, their behaviours might escalate, which means we might need to come back and review our assessments that we’ve already produced. (Hospital social worker)
2.3 Overall, we saw a narrowing of focus that prioritised only the most urgent situations at any time. The response was reactive rather than proactive, leading to a range of inefficiencies that undermined older people’s wellbeing.
You know, so when I started in social care, the complexity of the people that we were working with was nowhere near like it is now, because … people with lower level needs are signposted off to other services or they have a lower level of support. And by the time they come to needing a social worker, they’ve become quite complex. (Social worker)
For this answer, we cover the most important social care reforms that have not been implemented and highlight the main impacts on older people, carers and families.
3.1 Lack of action on recruitment and retention of workforce led to challenges recruiting, high vacancy rates, sickness, loss of experienced staff and services being described as at crisis-point.
This week on top of that we’re down a social worker who’s off sick. We’ve also got two posts for unqualified practitioners vacant, so that’s six posts across the entirety, of just our locality. Whereas all the other teams are in a similar position, if not worse. … I’ll be really honest and say that we’re fire-fighting at this point in time … So it’s at crisis point, and that’s what we’re responding to at the minute because we can’t look at the longer term stuff - that people that need their annual reviews, people that need the review of their carers assessment, but they’re not jumping up and down about it right now because everything is relatively stable. (Advanced Practitioner)
The main knock-on effects for older people were lack of social work input, lack of timely social work input, lack of experienced input, and lack of continuity of input. Older people and carers who had social work input valued the relationship, knowledge and practical support to uphold rights and achieve goals. Older people disliked discontinuity in relationships, social work that was limited in its remit and did not address their needs holistically, and social work that was absent when they needed it. However, timely and unbroken input from the same social worker was not possible.
So, we’ve had three social workers, but all over the phone. And when you call them back for some help, or advice, they’re no longer available. So Denis is the first one who actually phoned me up, introduced himself, and to ask to meet here, so he could meet mum and myself. And that’s what we did. And he has had contact with me every week. It’s been brilliant… He has been the most helpful one of every one of them, the whole of the social care. (Carer)
3.2 Lack of action to ensure that the statutory duties on prevention and on advice and information are met led to older people, carers and families only having input from social workers when the situation was complex or in crisis. Social workers are well-equipped with knowledge and skills to make a positive difference in preventative work, supporting people’s independence. However, they were not deployed to do this and it only happened in an ad hoc way.
It's a false economy because, as I was saying earlier, if we don’t support people in communities then they become more frail, typically, have greater needs, may end up going into hospital, become deconditioned so we’re not enabling them to promoting independence. I think that is another huge challenge as well, the health dominated agenda at a national level. The focus on hospital discharge, that’s what we hear about constantly. So again, it diverts attention away from people in communities. When the agenda if you like is dominated, when the space is dominated by a particular agenda, it leaves less space for exploring creative options and how we work with people who are living in communities. (Principal Social Worker)
Where older people did get good advice and information before crisis point this could be beneficial. Social work is a statutory service in its own right and could be beneficially provided as a therapeutic intervention for people facing sudden life changes such as hospital admission.
Example of the benefit of ad hoc input: The patient’s wife looked anxious and stressed, but as the social worker talked with her and explained the situation, [the patient’s wife] became visibly relieved and more relaxed. She seemed astonished at the practical help that was being offered by the social worker. The patient’s wife said ‘I can’t take it all in – it’s just amazing!’ The social worker offered to write it all down, in bullet points, for her to look at later and encouraged her to call any time. The patient’s wife seemed very relieved to have found that someone was going to support her, saying, ‘You can be my safety net, can’t you?’ (Researcher’s observation notes)
3.3 Lack of action on integration led to inefficiencies between health and social care caused by duplication of back office work, systems that didn’t talk to each other and social work posts being moved out of integrated settings. Other professionals and practitioners found a lack of continuity in social work support and lack of close integration between health and social care unhelpful. One site was taking social work posts that used to be situated in mental health teams back into generic adult locality teams.
But what the biggest frustration is, I have double everything. So double finance, double performance … I think the team is very integrated now and we’re seen as one team, but the sort of, hierarchy structure is still separate. (Integrated Care Service Manager)
Where integration was in place staff saw the benefits as being closer working relationships, more effective communication, holistic assessments and faster processes. Lack of clarity about who was responsible for different elements led to uncertainty and confusion. This was experienced most sharply in relation to Continuing Health Care (CHC) funding. Social workers found it difficult explaining and justifying these decisions to older people and their families. One social worker described a particularly difficult, but not uncommon, situation when an older person who was eligible for fast-track CHC funding for end-of-life care did not die within the expected timescale.
What he’s articulating is quite often what people do: “My wife hasn’t had the good grace to die, and now we’re arguing about money.” (Social worker)
3.4 Lack of action to ensure diverse and quality care services across the country led to lack of staff, issues with accessing care, avoidable crises and people getting stuck in the system including in care homes and hospitals, and to an impact on carers and families. This was exacerbated by ageism which meant that older people had access to more limited funding than working-age adults.
I think certainly it was interesting, wasn’t it, comparing and contrasting the assessment around the young person who was presented by the transition social worker, where we had a huge amount more information about [young person], how he liked to spend his time, what soothed him and everything going in, along with the eye watering cost of his care package. You compare that with, I think it was two or three [older] people we read through, who are all facing major, major challenges and changes to their lives. (Social Worker talking about a decision making process)
3.5 Failure to reform the Deprivation of Liberty Safeguards process may have contributed to the example of an older woman who was placed in a care home without a proper Deprivation of Liberty Safeguards assessment. The number and scope of assessments needed could not be met as there were insufficient qualified social workers to do this.
3.6 Not implementing the cap on care costs led to self-funders paying out more for care, running out of money and experiencing potential disruption in their care when they needed to ask for local authority funding due to reaching the means-tested funding threshold (capital drop). People who experience ‘capital drop’ could be living in a care home that charges more than the local authority would normally pay and this then causes a dilemma for the social worker. Such a situation could potentially be avoided by having a social worker’s input to help consider future needs and funding for self-funders at the point of their initial transition to a care home.
And again, there’s a lot of resentment from me, for somebody - I’ve paid since I was 16... And I’ve worked all me life. And I’ve worked through all sorts of things. And you know when you get to 65, and you think, ‘Hang on, why are they still charging me for things that I’ve already paid for?’ So I resent it. (Older man)
For this answer, we briefly highlight the main impacts on older people, carers and families (covered in question 1) and we provide a list of potential improvements.
4.1 The main costs of inaction to individuals are:
There is a direct impact on older people and on carers who would be eligible for support and do not receive this. There is a knock-on impact on carers, family, friends, neighbours and networks who have to step into the gaps in state support. This impact is emotional as well as physical.
4.2 We identified potential for improvements to wellbeing (including financial wellbeing) if action was taken in the following ways:
4.3 The impact of social work relational, legal and practical expertise is shown in this example:
The social worker was very good and she was very firm but professional, obviously, with the family. She kept bringing it back to the fact that it was about this patient, we were discussing a discharge plan for this patient. [Social worker} was very good at actually engaging with the patient and talking to her and asking her what she wanted. She made it all about her and asked her what she wanted...So [social worker] sat next to the patient. She engaged with her, looked into her eyes when she was talking to her and she was very, very positive at engaging with her. As a result now, we’ve come up with a plan for discharge...She led it…She was key in making sure that the conversation stayed firmly all about the patient...It was key that she was open and honest, and she ran that meeting. She was the person that was in charge of it all, if you like. (NHS Discharge co-ordinator)
For this answer, we summarise the financial impact on different elements of the system.
5.1 We identified financial costs across the system as follows:
Adult Social Care are key to any person’s discharge. They are very knowledgeable. They know things that not a lot of people know. They know what services are available out in the community. When patients are able to go home, they know what support is available, and they bring that to light here when discussing discharge plans. …So they’re very key and they’re very beneficial, obviously... If you were to take Adult Social Care out of the equation, I think the whole system would just collapse. They are key to ensuring that patients are safe, patients stay out of the acute hospitals. They provide support to no end to both families and patients, and the staff that they work with, their knowledge is second to none. They know what they’re talking about, they know how it operates and they support everyone the best they can, even if it’s staff as well. I’ve learnt so much. (NHS Discharge Coordinator)
For this answer, we propose how adult social care and social work can be considered in the economy and summarise where improvements can be found.
6.1 When social work and social care operate effectively they provide an efficient way of promoting wellbeing.
We identified the contribution of social care to the economy in the following areas:
For this answer, we propose how social care and social work in particular should be considered when evaluating policies.
7.1 Although named as a ‘key profession’ in legal guidance, social work is not usually specifically considered as a central contributor to effective social care. This contrasts with children’s services where social work is usually named. There are significantly more requests for help from older people than there are for children, but there are proportionately fewer social workers.[9] Despite the positive impact social work has, the benefits of it and the costs of not having social workers is often ignored.
7.2 Too often, discussions about reform lead to inaction which perpetuates inefficiencies and waste in the system, and the harmful impact of these on older people, carers and families. When weighing up the costs and benefits of reforms the following need to be considered:
7.3 Priorities for action and investment are:
8.1 There is no blueprint to how to ‘solve’ social care, but social workers are key and our research provides practical ideas about how their unique set of knowledge, skills and values can be harnessed for maximum benefit. The research also provides insight into the impact on people, services and systems of not undertaking reforms to adult social care. It therefore highlights important areas to consider in policy development.
Author: Geraldine Nosowska, Director, Effective Practice Ltd
9 December 2024
Lead researchers : Denise Tanner , University of Birmingham; Paul Willis and Phoebe Beedell, University of Bristol; Geraldine Nosowska, Effective Practice Ltd.
The views expressed are those of the authors and not necessarily those of the funder.
Consent was obtained to use participants’ information in the research and to share the findings.
All outputs from the research can be accessed at Social Work with Older People Research – Exploring the contribution of social workers to older people's well-being (wordpress.com).
Members of the research team would be happy to give oral evidence if requested.
9.1 Legislative and policy changes brought in by the Care Act 2014 were intended to uphold the rights of adults and carers who might be in need of care and support to a number of essential statutory services. Local authorities experienced an increase in demand and a decrease in real terms spending on social care from 2011 to the Covid-19 pandemic.[10] Key areas of development set out in the Care Act 2014 have not been realised with consequences including unmet, undermet or poorly met need,[11] and knock-on impacts on the NHS.[12] Reforms that have been announced are delayed including reforms to the Deprivation of Liberty Safeguards[13] and funding reforms.[14] Workforce reforms are needed to reduce issues with recruitment and retention for staff. [15] A joined-up social care and health response continues to be a work in progress. [16]
9.2 Recent reports have highlighted the need for reform to achieve the following outcomes:[17]
9.3 The extensive evidence available highlights the following impacts:
These impacts are exacerbated by inequity across the population.
December 2024
[1] Social Work with Older People Research – Exploring the contribution of social workers to older people's well-being
[2] Social Work with Older People Research – Exploring the contribution of social workers to older people's well-being
[5] Tanner et al 2024
[11] ADASS 2024
[12] Care Quality Commission 2024
[13] Care Quality Commission 2024
[14] The King's Fund 2023
[17] ADASS 2023; The Church of England 2023; Fabian Society 2023