Written evidence submitted by Think Ahead (ASC0079)

Adult social care reform: The cost of inaction

Evidence from Think Ahead

About Think Ahead:

Think Ahead is a mental health workforce organisation – we deliver a national programme that attracts, recruits and trains mental health social workers who work in NHS trusts and local authorities across England. To date over 1,100 people have joined our programme.

Social care has long been overlooked and under-invested in, and this is true for mental health social workers too. They are a key part of the health and social care workforce, but their role in health, and in bridging the gap between health and social care, is often misunderstood even by senior decision makers. We are seeing a worrying trend of mental health social work roles becoming more at risk - particularly in NHS trusts - due to pressures on services, partnerships between NHS and local authorities breaking down, and local authorities no longer deploying social workers in clinical settings.

Mental health social workers have a huge positive impact supporting people with severe mental illness. They support people to address social issues that profoundly affect mental health, including poverty, poor housing, abusive relationships, financial issues, and connection to community. There are over 31,000 social workers working in adult social care[1], and around 3,500 of these are employed by NHS mental health teams across England[2]. 

Mental health social workers embody integration and they will play an integral role in helping government with its three shifts – from hospital to community; analogue to digital; sickness to prevention.   

We believe that reform in adult social care needs to prioritise having a properly resourced workforce, with meaningful support for practitioners. Mental health social workers do an incredibly challenging job, and in order to give the most effective care to others, they need to be supported themselves.

Because of the nature of our work, our response will focus on the workforce, and on mental health social workers in particular.

1. 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?    

At the moment, the workforce is not fit for purpose. Practitioners are struggling, ways of working are inefficient, and there are insufficient budgets to provide the support people need. Mental health referrals increased by over a third between 2019 and 2023[3], and the workforce is not able to meet this increased need.

Inaction on adult social care reform is having a huge impact, and reform is urgently needed. Without this, things will continue to deteriorate.

And reform must go hand in hand with investment. We can’t expect meaningful reform to happen without investment, but investment on its own won’t bring about the changes that are needed.

We have focused the rest of our answer to this question on recruitment and retention challenges, and on inefficiencies and insufficient funding, as these are areas that we know urgently need reforming.

Recruitment and retention challenges mean that:

         There are not enough staff to meet patients’ needs. The adult social care sector has a higher vacancy rate than the NHS and the economy as a whole[4].

         Existing staff feel over-stretched and unable to give the care needed. Nearly two-thirds of social workers report that their caseloads are unmanageable, while 97% reported that vulnerable people would be better protected if caseloads were lighter[5].

         There are gaps in care while staff are recruited. This has a huge impact in social work where relationships between practitioners and patients are key. Members of our Lived Experience Partnership tell us that the relationship they build with their social worker is vital to them feeling understood and being able to progress. In our research, a social worker told us: “The lack of continuity of care is the biggest complaint I get from service users, they hate the changeover”[6].

         Money is spent on short-term agency staff, and on recruitment. The use of agency social workers has increased by 25% in adults’ services between 2022 and 2023[7]. Skills for Care estimated that it costs up to £3,600 to recruit a replacement care worker in the health and social care sector[8]. And this cost doesn’t take into account the cost of onboarding and training practitioners once they are recruited.

Inefficiencies and insufficient funding are common throughout the NHS and local authority workforce. For example:

         A lack of modern and integrated technology, systems and processes make work less efficient. Resolving this issue, and investing in getting the basics right as well as in new technology, will be vital for the government’s planned shift from analogue to digital:

• Our research found that 70% of social workers in mental health settings found poor IT affected their work, and nearly 10% said their internet connection was so poor they were often unable to work6.
• Too much time is spent on paperwork and admin. For example – NHS and local authorities have different systems for storing information about patients. Practitioners spend time uploading information to two systems, or may be only able to upload to one, meaning key information isn’t shared, or they have to spend time chasing other organisations to share information.

         Packages of care are not meeting people’s needs – social workers sometimes need to step in to help with basic tasks (e.g. shopping or paying a bill) that could be done by another practitioner such as a support worker, but where this support has not been provided due to funding constraints. This takes social workers away from other crucial elements of their roles and leads to stress in not being able to provide the support that people need.

         There is a lack of clarity about roles. One social worker told us: “I have recently started a new job as a transition worker between Child and Adolescent Mental Health Services and Adult Mental Health Services, there is such poor communication between the two and no clear guidance on my role or what might optimise positive change for these young people”6. Another said: “I can deal with stress of being overworked and having so much on my plate, but only if I feel a sense of control. I don’t really know what my job is meant to be. I keep being asked to do things that I’m not supposed to be doing anymore. I don’t feel anyone has any clarity over roles.”6.

These issues all create a challenging environment for practitioners, leading to low morale. Many people leave owing to the pressure services are under, with almost 50% of mental health social workers showing significant levels of distress, burnout and emotional exhaustion[9].

And it’s a cycle – when people leave, pressure is increased amongst remaining staff, which leads to them feeling overstretched and more likely to leave.

2. 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?   

A key reform that’s not working as it should is integration of NHS trusts and local authorities.

The benefits of joined up care are clear, and NHS, local council, voluntary sector and social care providers have joined up through Integrated Care Systems.

This should lead to more holistic and consistent care. In some areas, section 75 agreements (a partnership agreement between NHS bodies and local authorities) have supported this way of working.

The benefits to the workforce are great – but especially to social workers, who have a unique role spanning both NHS and local authorities. Better integration means more efficient working, more joined up care, and less duplicating of work. This is evidenced in November’s Health Services Safety Investigation Body (HSSIB) report on Out of Area placements[10] which highlighted that section 75 arrangements have improved efficiency and collaborative working, and greater understanding of cross-system pressure.

However - in some areas, meaningful integration between NHS trusts and local authorities isn’t happening, and in others section 75 agreements have been revoked due to operational pressures.

Where organisations are not working together, there can be delays, arguing between services about whose responsibility it is to resolve something, and extensive referring and chasing between the two. The HSSIB report also found that section 75 separations have the unintended consequence that social workers without any mental health experience are being assigned to support patients with mental health needs10. This means people are not getting the specialist support they need.

While the reasons for the breakdown of section 75 agreements are complex, the potential benefits of resolving them would be hugely positive to the workforce and patients.

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

As it stands, the system is failing people, unable to deliver support they need when they need it. Social care waiting lists have grown over the last few years. Over 400,000 people were recorded to be waiting for an assessment, review, direct payment or care package in March 2024 and the number of people waiting six months for an assessment has doubled between 2021 to 2023[11].

One person told us: “Being told they know what you need to feel better and then being told that it is not available in your area, or that it is months to wait, causes more harm than good. You actually get worse waiting for that support because it feels like life can’t start until the help starts.”[12] 

It’s not just waiting lists that are a problem. Mental health social workers are often unable to give the level of support that people need, because they are overstretched and don’t have sufficient resources. One social worker told us: “Our morning meetings are all just about who is taking their medication and who isn’t – not because we don’t care about the other things, but because there isn’t any time to speak about anything else because there are so many cases.”12.

Without adequate care, people are more likely to deteriorate and require crisis care and A&E support. For example, the Royal College of Psychiatrists found that two fifths of patients waiting for mental health treatment contact emergency or crisis services, with one-in-nine (11%) ending up in A&E[13]. Of those on hidden waiting lists (those who are waiting between referral and second appointment), more than three quarters reported they were forced to resort to emergency services or crisis lines[14].

This obviously has a social and psychological cost to people. But ongoing mental health problems also have significant financial and economic costs to individuals. For example:

• Many will be unable to work. Researchers at the University of Amsterdam found that for every one month someone is on a waiting list for mental health support, their chance of having a job long-term reduces by 2 percentage points[15].
• The Money and Mental Health Policy Institute report that people with severe mental illness are 2.3 times as likely to experience money or debt problems[16], and that while unwell, 63% with mental health problems found it harder to make financial decisions, with 42% of people putting off paying bills and 38% of people taking out a loan they otherwise would not[17].
• There is a strong link between homelessness and mental health problems with Homeless Link research showing 82% of people experiencing homelessness have a mental health diagnosis[18].

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

We are seeing that our NHS trust and local authority partners are experiencing unprecedented challenges with workforce planning because of financial uncertainty, and mental health social work roles are becoming more at risk.

When organisations partner with Think Ahead to train social workers, they commit to providing salaried jobs for their trainees once they qualify and register with Social Work England. In the last year, some partners have been unable to commit to these jobs because of budgetary pressures and uncertainties. Of the organisations who have partnered with us for our 2024 intake, 35% are unable to partner with us for 2025 because of financial insecurity. This is up from 20% the previous year and is affecting NHS trusts more than local authorities. 

Without long term financial planning capabilities NHS trusts and local authorities are unable to commit to providing social work jobs to trainees from their local communities who are committed and capable, yet millions of pounds are being spent on contracts to fill vacancy rates with social workers from overseas. For example, in November this year a tender was published for £30m for an undefined number of adult social workers from abroad to join London local authorities.

While we understand that recruiting social workers from abroad may seem helpful - because they are already qualified, and because their visas can require them to stay in the role for a certain length of time - this is really only a short-term sticking plaster, and it creates new challenges with upskilling social workers in our systems and processes. There are also huge ethical considerations in taking social workers from other countries who also need them. 

We receive 90 registrations for every place on our mental health social work programme – so we know there is plenty of interest from people in local communities. Rather than plugging resourcing gaps with staff from overseas, money would be better spent improving working conditions and providing people with the support they need to enjoy long fulfilling careers.

It is also key to invest in workforce planning, and we are calling for the new NHS workforce plan to include a target to grow the number of mental health social workers.

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

When mental health social workers are supported to perform at their best, they are working towards providing long-lasting, sustainable improvements for the people they support, enabling them to live more independent lives.

Their work makes two key contributions to the economy:

When people are well, they are more likely to work

Only 43% of people with mental health problems are in employment compared to 74% of the general population16. In 2022/23, almost 24 million working days were lost due to stress, anxiety and depression[19]. Deloitte research shows that poor mental wellbeing costs employers in the UK an estimated £42-45 billion annually through presenteeism, sickness absence and staff turnover[20]. And the Centre for Mental Health estimates that lost tax revenue (in unemployment and economic inactivity) due to mental ill health amounts to £5.7 billion[21].

When people receive the care and support they need, they are more likely to get well and stay well – and be able to work and contribute to the economy.

When people are well, they are less reliant on services

When services are running effectively, social workers support people in the community to become more independent and less reliant on services. The Local Government Association found that investing in preventative support can save more than £3 for every pound spent – a potential saving of £11.1 billion to the public purse if preventative health and social care is scaled up across the country.[22]

If the government wants to move from sickness to prevention, they need more mental health social workers, who can enable people with mental health problems to become less reliant on services. They can provide long-term care in the community and reduce the need for A&E or crisis service support, and hospital care – which is expensive, but also often ineffective. Research has shown that hospital admissions can worsen patients’ mental health[23] and investing in community care can see a 15% lower admission rate to hospital[24].

6. 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? 

NHS and social care budgets need to be looked at together – the two are intrinsically linked and until there is reform and sufficient funding across both, many people won’t get the support and care they need.

While it was positive to see increased NHS spending in the most recent budget, the social care sector is also in desperate need of better funding, and both systems should be assessed and evaluated together.

The aspiration of integrated care has been around for a long time, and Integrated Care Systems and Integrated Care Boards are a practical output of that ambition – with Joint Forward Plans intended to analyse workforce challenges across local services and create solutions based on the needs of the local population. And yet we still see significant issues on the ground of joint working between local authorities and NHS trusts. This problem needs to be properly understood, so that services can be supported to work towards meaningful integration. This will have enormous benefits for the workforce and for patients.

We are signatories to the Centre for Mental Health’s A mentally healthier nation manifesto[25], which called for (amongst other things):

-          A cross-government mental health strategy.

-          The creation of a statutory mental health commissioner for England with the necessary powers, resources and independence from government.

These changes would play a part in developing more effective policies and financial decisions for the whole adult social care system.

December 2024