Written evidence submitted by British Geriatrics Society (ASC0047)

Inquiry into the cost of inaction on social care

The British Geriatrics Society (BGS) is pleased to be contributing to this important inquiry looking at the cost of inaction of social care.

1.1   About BGS
The BGS is the membership organisation for all healthcare professionals engaged in the treatment and care of older people across the UK. Since 1947 our members have been at the forefront of transforming the quality of care available to older people. Our vision is for a society where all older people receive high-quality patient-centred care when and where they need it. We currently have over 5,200 members working across the multidisciplinary team, including geriatricians, nurses, GPs, allied health professionals and pharmacists and across acute, primary and community care settings.

1.2   Healthcare for older people is intrinsically linked to social care. Our members see the impact of the crisis in social care on their patients and on the wider health system. For too long, social care has been seen as the problem, causing older people to be admitted to hospital as they cannot access the care they need at home as well as contributing to delayed discharges for the same reason. It is important to reframe this conversation to acknowledge the social care sector as part of the solution. A social care system that is sustainably resourced and fit for purpose can help the NHS to address many of its challenges by supporting people at home and reducing unplanned hospital admissions and providing care for people once they are discharged from hospital.

2. How much is inaction on adult social care reform costing the NHS and local authorities, and what impact does this have on patients and the public?

2.1   At any given time in England, 13,000 people are in hospital who no longer meet the ‘criteria to reside’ – that is, they are medically well enough to leave. However, they are unable to do so, because they cannot access the care they need in the community. Research from the Health Foundation found that social care was either partly or completely responsible for 40% of delayed discharges with the remainder caused by lack of rehabilitation in the community or slow discharge procedures within the NHS.[i] Data provided in answer to a Parliamentary Question in 2023 states that the average cost of a non-elective bed day, including treatment, is £901.[ii]

2.2   Using this data, basic calculations suggest that 5,200 people are in hospital who medically do not need to be there because of a lack of social care and that, on average, the NHS is spending £901 per person per day on keeping these people in hospital. This works out as more than £4.5million per day or £1.7billion per year. This is a very basic calculation which may exclude other factors. However, it suggests that inaction on social care is having a considerable financial impact on the NHS.

2.3   The majority of people in hospital waiting for social care are older people who do not want to be there. Many of these people are in their last months and years of life and spending this time in hospital when they do not need to be there is not a good use of their final months. 60% of hospital beds are occupied by people aged over 65[iii] and 80% of people aged 75 and older have at least one hospital admission in the last year of life.[iv] 43% of deaths occur in hospital, despite the fact that many people do not need or want to be in hospital at the end of their lives.[v]

2.4   Older people who get stuck in hospital are at risk of the common, costly and distressing hospital acquired complications; deconditioning which occurs as a result of lack of mobility resulting in reduced muscle strength and independence, delirium or acute confusion resulting in demotivation, increased risk of falls, and institutionalisation. While these complications can be prevented through simple interventions such as ensuring older people get out of bed, dressed and moving every day, many hospitals experience difficulty in supporting patients to do this as they do not have the staff or necessary equipment available for patients to sit out of bed. As a result, the window of opportunity for meaningful rehabilitation of older people is lost and patients are discharged with greater care needs.

2.5   While social care includes both care homes and domiciliary care, it is important to remember that most older people are living in their own homes rather than in care homes. Around 80% of those aged over 90 live in their own homes and only 4% of those aged 80 to 84 live in care homes.[vi] Provision of good quality domiciliary care to help older people to live at home for as long as possible is beneficial to individuals as well as providing cost savings for society.

2.6   Older people who are in receipt of social care services must also have good access to healthcare when they need it. The Enhanced Health in Care Homes Framework is making inroads into providing medical care in care homes and reducing unnecessary hospital conveyance for care home residents. BGS’s Ambitions for change document sets out what good quality healthcare in care homes looks like.[vii] However, too many older people, especially those living in their own homes, are conveyed to hospital when they could be better cared for at home by health and social care services working together. This has a non-financial cost to an individual who may not wish to be conveyed to hospital and may experience deconditioning and delayed discharge as well as having a financial cost to the system.

3. What NHS and local authority service reforms are not happening as a result of adult social care pressures, and what benefits are patients and the public missing out on?

3.1   It is difficult to say precisely that specific reforms are not happening because of a lack of social care as there are pressures across the system and they all contribute to progress being stymied. Framing the question in this way further suggests that the social care sector is the problem rather than part of the solution.

3.2   However, as previously mentioned, there are people who remain in hospital who cannot be discharged due to the lack of availability of social care. This does contribute to problems throughout the system, including people getting stuck in emergency departments as they are unable to be transferred to wards due to a lack of available beds. This in turn contributes to ambulances queuing up outside hospitals, unable to transfer patients into emergency departments, which in turn contributes to delays in ambulance response times. While social care reform should not be seen as the answer to all the problems facing the health and social care service, it would help to improve the situation for older people across the whole system.

4. What is the cost of inaction to individuals and how might people’s lives change with action on adult social care reform?

4.1   Lack of public understanding about social care funding means that many individuals and families are caught by surprise when they or their loved ones need social care and may be required to at least partly fund this themselves. They assume that social care is provided on the same basis as healthcare through the NHS, i.e., free at the point of delivery. For many people, the current rules may require them to sell their homes to pay for social care – something that many people find difficult, especially if it is unexpected. Some people will find this upsetting, as they may have hoped to leave their property to loved ones as an inheritance.

4.2   In addition, people who do have significant savings and assets are likely to be able to self-fund a different level of care to those who have more limited means and therefore rely on local authority funding. This results in a two-tiered system.

4.3   While any reform to the system is unlikely to completely remove the financial burden of social care from individuals and families, more clarity about what is paid for from local authorities and what people will need to fund themselves will lessen the shock of having to pay for social care unexpectedly. However, to achieve this, any reform of social care must be accompanied by a public campaign to increase awareness of social care costs. This would allow people to prepare for the possibility of needing social care.

4.4   Inaction on social care of course has the biggest impact on individuals who require social care to live independently and we do not seek to minimise the significance of this. However, inaction on social care reform also has an impact on healthcare professionals as many in the sector are poorly paid and work under extreme pressure. Those working in the social care sector do crucial jobs, looking after some of the most vulnerable people in our communities, often on minimum wage and with minimal training and support. Those providing care in people’s homes are often required to complete their visits in a limited time period and are not paid for travel time between clients. As a result, the care provided can be rushed which is detrimental to those receiving care and causes moral injury to those providing care who are often not able to provide the high level of care that they would wish to provide.

5. Where in the system is the cost of inaction on adult social care reform being borne the most?

5.1   It is important to view the system as a whole and not to consider social care as the cause of all the problems across the system. Inaction on adult social care affects the whole system, along with other factors including lack of rehabilitation in the community and poor discharge procedures.

5.2   BGS has published Joining the dots:  A blueprint for preventing and managing frailty in older people which sets out what good quality, age-attuned care for older people looks like. This document uses seven touchpoints which are essential components of care – Enabling independence, promoting wellbeing; Population-based proactive anticipatory care; Integrated urgent community response, reablement, rehabilitation and intermediate care; Age-attuned acute hospital care; Reimagined outpatient and ambulatory care; Enhanced healthcare support for long term care at home and in care homes; and Co-ordinated, compassionate end of life care.[viii] While there are plenty of example of good practice in older people’s healthcare across the country, we are not aware of any system that provides excellent care across all seven touchpoints. This cannot be attributed to social care specifically. However, a functioning social care sector would reduce pressure and mean that systems may be able to focus on delivering care across the seven touchpoints.

6. What contribution does adult social care make to the economy and HM Treasury and how might this change with action on reform?

6.1   No comment

7. To what extend are the costs of inaction on adult social care reform considered by the Government when evaluating policies, including within the Budget and Spending Reviews? How should these costs be assessed and evaluated?

7.1   No comment

Thank you for the opportunity to contribute to this important inquiry. If you require further information from the BGS or would like one of our expert members to provide oral evidence to the committee, please do not hesitate to contact our Policy Manager, Sally Greenbrook who will be able to make the necessary arrangements.