Written evidence submitted by Royal College of Occupational Therapists (ASC0074)
Royal College of Occupational Therapists response to Health and Social Care Committee inquiry – Adult Social Care Reform: The Cost of Inaction
We’re RCOT, the Royal College of Occupational Therapists. We’ve championed the profession and the people behind it for over 90 years; and today, we are thriving with over 36,000 members. Then and now, we’re here to help achieve life-changing breakthroughs for our members, for the people they support and for society.
Occupational therapists (OTs) play a vital role helping people overcome challenges completing everyday activities (occupations) that add purpose to their lives. They assess individuals using a person-centred approach to identify their needs and work co-productively to agree the goals that people wish to achieve. Their interventions enable people to thrive and live fulfilling lives. OTs in social care work in adults', children’s and housing services, as well as in learning disability teams, prisons and in public health.
OTs are integral to the success and sustainability of social care services. They enable people affected by long-term illness and disability to participate in a wide range of daily activities. This includes supporting people to maintain or regain independence in tasks such as personal care, meal preparation and household chores. It also includes enabling people to fulfil their work and caring roles. By delivering elements of the Care Act 2014, they play a paramount role in preventing, reducing and delaying the need for statutory services and meeting the profound care needs of the population.
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?
Workforce pressures
Inaction on adult social care reform has put occupational therapy services under considerable strain. The RCOT workforce survey 2022-23 found that 78% of OTs felt their team wasn’t large enough to meet demand, with 63% saying they were too busy to provide the level of care they’d like (RCOT, 2023). Skills for Care reports national vacancy rates of 9.5% for OTs in social care (Skills for Care, 2024a) and there are barriers to the recruitment and retention of OTs in social care due to the disparity in pay, terms and condition between OTs employed by the NHS and OTs employed by local authorities. The Workforce Strategy for Social Care in England (2024) recognises that this exacerbates the social care workforce crisis and recommends that OTs employed by local authorities should have comparable pay, terms and conditions to those on NHS Agenda for Change contracts (Skills for Care, 2024b).
Impact on the public
Despite constituting only 4% of the regulated social care workforce, OTs intervene in around 35-45% of local authority referrals (RCOT, 2019a). Inaction has led to under-resourcing of OT services, which is significantly affecting many individuals accessing social care. Long waiting times to receive OT input can result in deterioration of people’s health and independence, which in turn leads to an increase in their support needs. They may also be at increased risk of accidents such as falls, which can lead to a need for acute or emergency care. Both their physical and mental health can be affected, and they may be less able to participate in work or education. Additionally, they may be unable to fulfil important roles such as parenting and caring for others.
The impacts are not limited to the individual, with families and loved ones also affected. Where a person’s support needs increase, family members are often relied upon to provide informal care, which can strain their ability to manage their own responsibilities, including work and parenting.
Impact on the health and care system
Individuals being unable to receive OT input places additional strain on already over-burdened areas of the health and care system. Specifically:
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?
Improved hospital discharge
OTs are key to the management and delivery of local authority reablement and adaptations services. When adequately resourced, these services enable people to be discharged from hospital sooner and achieve a higher level of independence in daily activities (ADASS, 2024). At present, many reablement and adaptations services are unable to react quickly to the needs of people awaiting discharge. In October 2024, over 2,100 people who no longer met the criteria to reside remained in hospital for over 14 days due to reablement, rehabilitation and adaptations not being arranged or available (NHS, 2024). Prolonged stays in hospital can lead to deconditioning, and an increased need for care when people are finally discharged.
Implementation of the Intermediate Care Framework
The effective implementation of the NHS Intermediate Care Framework (2023) is a key pillar of the shift to a neighbourhood health approach. The Framework recognises that community-based, therapist-led assessments and interventions result in improved outcomes and independence for people discharged from hospital. Additionally, they reduce hospital admissions and reliance upon long-term care. To implement the Intermediate Care Framework effectively, local authority reablement and social care OT teams must have adequate capacity to respond rapidly to those being discharged from hospital.
Preventative interventions
Preventative measures and early interventions are essential for managing health conditions, reducing hospital dependency, and enhancing life quality. Statutory guidance under the Care Act (2014) emphasises that OTs are effective in preventing, reducing, or delaying care needs and possess a holistic perspective that includes a person’s strengths and informal support networks. They provide adaptations, equipment and assistive technology that promote independence, prevent falls, and reduce hospital admissions.
Lack of capacity and resource within social care and housing OT teams limits their ability to intervene in a preventative way. Most OT assessments and interventions happen only after people have already experienced an accident or deterioration in health and independence. Additionally, the OT workforce is disproportionately concentrated in inpatient settings, limiting their preventive impact. Addressing this misalignment and increasing the capacity of community-based OTs is crucial to maximising their contribution to public health. The RCOT Workforce Strategy (2024) is clear that, in order to optimise the availability and impact of occupational therapy, more of the OT workforce should be based in communities.
Rapid housing interventions
OTs play a crucial role in creating accessible housing environments that promote health and independence. Adaptations to the home environment can completely transform the lives of older and disabled people by enabling them to function more easily and safely in their homes. Adaptations can prevent falls, reduce hospital admissions, accelerate hospital discharge, reduce reliance on care, avoid the need to move into residential care and significantly improve quality of life and wellbeing for individuals, their families and carers.
The NHS Intermediate Care Framework (2023) urges systems to plan and deliver home adaptations at an early stage to facilitate timely hospital discharges. Disabled Facilities Grant (DFG) delivery: Guidance for local authorities in England (MHCLG, DHSC, 2022) recommends use of Adaptations Without Delay (RCOT, 2019b) to improve the efficiency of adaptations teams by making best use of the available workforce. In practice, workforce challenges and financial constraints make it difficult for adaptations teams to change their processes. This can result in waiting times of months or even years for adaptations to be completed (Bureau of Investigative Journalism, 2022). During this time people’s needs can become more significant, their ability to participate in daily activities can reduce and their likelihood of accidents in the home can increase.
The DFG funding limit of £30,000, alongside the current DFG means test, also creates delays and results in people not receiving the adaptations they need. This increases the likelihood of people needing to move from their own homes into specialist accommodation or residential care, which is much more costly in the long term. The cost of providing adaptations is increasing, but the DFG funding limit has not kept pace. This means that the number of people failing to receive adaptations due to the funding cap is ever-increasing.
Public health approaches
The Royal Society for Public Health (RSPH) promotes the potential for OTs to lead and deliver population-health interventions focused on physical, mental and social wellbeing. There are local examples of OTs leading innovative programmes such as online physical activity services for marginalised groups, supporting women who have experienced domestic violence, and working with fire services to reduce fire risk and address health and wellbeing in vulnerable communities (RSPH, 2023). At present, many of these programmes are short-term due to lack of ongoing funding. There is significant scope to increase the impact of OTs in addressing health inequalities and social determinants of health through increased resource.
What is the cost of inaction to individuals and how might people’s lives change with action on adult social care reform?
Please refer to our response to questions one and two.
Where in the system is the cost of inaction on adult social care reform being borne the most?
Failure to reform social care places additional strain on areas of the health and care system which are high-cost and already under significant pressure.
Acute and urgent care
Preventable accidents and illnesses resulting from unsuitable homes are very common, especially for older people. This creates pressure on primary care, ambulance services, acute and urgent care. If housing adaptation and equipment services were able to intervene sooner, much of this pressure could be avoided.
Falls in older people cost the NHS more than £2.3 billion per year, with a third of people over 65 and half of people over 80 falling at least once a year. Research completed by Health Data Research UK showed that home adaptations reduced the number of falls requiring an emergency or hospital admission by 3% per quarter (Hollinghurst et al, 2022)
Residential and nursing care
Lack of capacity within social care and reablement teams can result in people moving into residential or nursing care inappropriately or prematurely. This is due to: deterioration in health whilst awaiting home adaptations; pressure to be discharged from an acute hospital and the person’s home isn’t suitable for them; lack of availability of home-based care (Age UK, 2024).
The majority of older people wish to live independently in their own home (SCIE, 2021) so there is a personal and social cost to people moving to residential care. This is alongside the financial cost of residential placements.
Domiciliary care
OT-led reablement services are effective in enabling people to regain or retain their ability to participate in everyday activities. This leads to reduced reliance upon domiciliary care in the long term (ADASS, 2024). However, access to reablement is inconsistent across the country, and not all reablement services include OT expertise. This reduces the rehabilitative focus of reablement services and leads to an avoidable, ongoing reliance upon care and support for some individuals.
Informal carers
Lack of availability of reablement and accessible housing impacts unpaid carers as well as the formal care sector. There are 2.5 million unpaid carers in employment in England and Wales, and 75% of employed carers worry about their ability to juggle work and care (Carers UK, 2022). 2.6 million people have given up work to care, and an additional 2 million people have reduced their working hours to care (Carers UK, 2023). This increases the risk of health issues and poverty for individuals and has a negative impact on the economy. Greater investment in reablement, housing and adaptation services would result in care needs being reduced, delayed or eradicated.
What contribution does adult social care make to the economy and HM Treasury and how might this change with action on reform?
There are many examples of OT-led projects and services that improve outcomes for people and reduce costs for local health and care systems. At present the availability of these services is inconsistent across the country. By scaling OT-led approaches such as those described below, greater numbers of people and localities would benefit, resulting in significant cost savings nationally.
Optimised handling reduces care costs and bed days
OT-led programmes enable systems to review their approach to moving and handling, ensuring that care packages are proportionate to the person’s needs. This promotes participation in daily activities, enables people to be discharged from hospital sooner, and reduces demand upon domiciliary care.
Case studies from the optimal handed care project delivered by Tower Hamlets council, East London NHS Foundation Trust and Barts Health NHS Trust identified indicative weekly care cost savings to the local authority of £630 in one case and £450 in another.
The single-handed care pilot led by OTs from University Hospital Southampton NHS Foundation Trust saved 2,872 bed days over 12 months. 272 people were discharged directly home with a reduced care need.
OTs at Telford and Wrekin council created a pilot team focused on supporting informal carers with manual handling. Over £900k of commissioned care was prevented by enabling informal carers to safely use manual handling equipment so they could continue to deliver care themselves (ADASS, 2024)
Reablement and rehabilitation reduce care costs and pressure on hospitals
OT-led reablement services foster a rehabilitative and personalised approach that enables people to be discharged from hospital successfully and reduces reliance upon long-term care packages.
Following intervention by Wigan Council’s Early Intervention Team, 91.7% of people receiving reablement no longer required ongoing support (RCOT, 2019a).
Rutland Council’s reablement team has incorporated seven day working to ensure efficient hospital discharges and admission avoidance. Without weekend working, delays to reablement commencing would have totalled 23 days for 2022 and 46 days in 2023. The impact to the person of a two day delay to starting reablement is a likely decrease in functional abilities and an increase in care and support needs (ADASS, 2024).
OT intervention reduces reliance upon long-term residential care
Coventry Council operate an OT-led approach for all people discharged on pathway three of the Intermediate Care Framework, which are health-funded residential or nursing beds. In the first year of this approach, 40 people were discharged from long-term residential care to home, compared to eight people the previous year (ADASS, 2024)
Adaptations enable people to stay in their homes
The BATH-OUT research study identified positive lived experiences for a cohort of older people who had received level access shower adaptations. These effects were still evident 28 months post-installation. Participants reported an increased likelihood of remaining in their own homes, due to increased confidence and autonomy in their physical environment (Golding-Day & Whitehead, 2020)
Research commissioned by the Centre for Ageing Better identified strong evidence that home adaptations are a successful and cost-effective intervention for preventing falls and injuries, improving performance of everyday activities and improving mental health (Centre for Ageing Better, 2017)
To what extent 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?
It is vital that the cost of inaction on social care is considered broadly. As demonstrated in our previous answers, action or inaction in social care has a direct impact upon the NHS, the housing sector and employment rates.
The impact of social care interventions is often felt elsewhere in the economy, so the success of social care services cannot be solely measured by looking at the expenditure of local authorities. Many social care interventions delivered by OTs prevent the need for additional health and care interventions in the future, and the financial and personal impact of prevention is difficult to quantify. For example, a housing adaptation that enables a person to bathe independently not only reduces care costs but also reduces the likelihood of falls. If falls don’t occur, injuries are avoided and demand upon ambulances, acute care, inpatient services and surgical interventions is reduced.
The Government should take action to ensure that data is available to quantify the costs and benefits of social care across the economy.
References
ADASS (2024) ahp-project-report-jun-24-final.pdf
Age UK (2024) the-disabled-facilities-grant-a-step-change-improving-delivery-of-the-disabled-facilities-grant.pdf
Bureau of Investigative Journalism (2022) Disabled people trapped waiting years for vital home… | TBIJ
Carers UK (2023) Carers’ employment rights today, tomorrow and in the future
Carers UK (2022) cukstateofcaring2022report.pdf
Centre for Ageing Better (2017) Room to improve: The role of home adaptations in improving later life | Centre for Ageing Better
Foundations (2022) Comprehensive Evidence for Disabled Facilities Grants (DFGs) | Foundations
Golding-Day & Whitehead (2020) https://bmjopen.bmj.com/content/10/11/e035701
Hollinghurst et al (2022) https://doi.org/10.1093/ageing/afab201
MHCLG, DHSC, DLUHC (2022) Disabled Facilities Grant (DFG) delivery: guidance for local authorities in England - GOV.UK
NHS (2024) Statistics » Discharge delays (Acute)
RCOT (2024) Workforce Strategy - RCOT
RCOT (2019a) https://www.rcot.co.uk/file/4068/download?token=RNJL4Lt6
RCOT (2019b) Home Adaptations Without Delay Planning Guide - RCOT
RSPH (2023) RSPH | Case Studies
Skills for Care (2024a) The state of the adult social care sector and workforce in England, 2024
Skills for Care (2024b) A Workforce Strategy for Adult Social Care in England
Social Care Institute for Excellence (SCIE) (2021) Population survey - SCIE
December 2024