Written evidence submitted by NHS Providers (ASC0109)

Health and Social Care Select Committee inquiry into Adult Social Care Reform: The Cost of Inaction

NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS foundation trusts and trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate. 

NHS Providers has all trusts in England in voluntary membership, collectively accounting for £124bn of annual expenditure and employing 1.5 million people. 

Our evidence will focus on the following issues set out in the terms of reference:

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

Key points:

• The NHS and social care are two sides of the same coin; one cannot meaningfully function without the other.
• Although trust leaders welcomed the additional £22.6bn of funding for the NHS from 2023-24 to 2025-26, they are acutely aware that the effectiveness of their work is inextricably linked with that of the social care sector. Additional funding for the NHS will therefore fail to have maximum impact without equivalent action and support for the social care sector.
• The failure of successive governments to reform adult social care has led to challenges meeting demand for care, which in turn has significant consequences for the wider health and care system.
• There are currently 131,000 staff vacancies in social care, and new figures show a significant drop (65%) in health and hare worker visa grants over the last year. This is very concerning given the existing gap between capacity and demand.
• To redress the challenging situation in social care, the government’s manifesto pledged to reform the sector by creating a ‘National Care Service’, underpinned by national standards, delivering consistency of care across the country. The manifesto also committed to establishing a Fair Pay Agreement and building consensus for the longer-term reform needed in the sector.
• Since being elected in July, the government has made NHS reform and delivery a key area of focus. There has been a rapid review of the NHS carried out by Lord Ara Darzi over the summer, and the development of a 10-year plan for health is now underway and set to be published next year. While we welcome many of the government’s ambitions for the NHS, it is vital that there is meaningful action to support social care, and an equivalent 10-year plan to support the sector.
• In the government’s first budget, local authority services received a real terms increase in core local government spending power of around 3.2%, including at least £600 million of new grant funding to support social care. While this new funding will provide some short-term support for local authorities and social care providers amid increasingly challenging financial pressures, it will not deliver the meaningful reform needed in the sector, and fails to cover the £3.4bn of additional cost pressures estimated by the LGA for 2025/26, compared  to 2024/5 .
• Within the budget, the government also announced an increase in employer national insurance contributions to raise revenue to fund public services. We welcome the commitment from the Treasury to compensate NHS trusts for the cost of the uplift as part of their spending envelope. However, we remain concerned by the lack of parity for social care providers who will have to fund the uplift themselves.
• A survey by the Care Provider Alliance highlights the significant impact this will have on social care providers, with 73% of providers stating they will need to refuse new packages of care from local authorities or the NHS, 57% stating they will need to hand back current contracts, and 64% stating they will need to let staff go. This is not only consequential for individuals, who may be forced to go without the care they need to stay well in the community. It will also have a knock-on impact for the NHS in terms of delayed discharge and demand for urgent and emergency services.

• Ignoring the crisis in social care is no longer an option. Urgent action is needed to ensure all those who need it can access the right care, at the right time, in the right place. The sector needs long-term, sustainable funding and reform which addresses unmet and undermet need, quality of care, and workforce shortages. 

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?  

1.       The NHS is facing significant operational pressures. In September 2024, the elective care waiting list was 7.57 million (3 million more than in July 2019), and 2024 is on track to be the busiest year ever for accident and emergency (A&E) departments. While there are a complex set of factors contributing to this, pressures in social care are having a significant impact.

2.       In October 2024, there were an average of 22,660 patients who no longer met the criteria to reside in hospital on any given day, and of these, 54.5% remained in hospital.

3.       Pressures in social care are not the only cause of delayed discharges; hospital discharge process and waits for NHS community care are both contributing to this. However, research by the Nuffield Trust shows that, for patients whose discharge has been delayed by 21 days or more, a high proportion of delays are attributed to services organised predominantly by social care.

4.       The impact of delayed discharges on patients can be significant, with long hospital stays contributing to the risk of people being exposed to healthcare acquired infections, deconditioning, and a general deterioration in their sense of independence and wellbeing. This is especially true for older people and those with frailty.

5.       Delayed discharges also impact the wider health and care system, contributing to pressures across the urgent and emergency care pathway, as well as limiting bed capacity to tackle the elective care waiting list.

6.       In October 2024, there was a significant jump in the number of patients that waited in A&E for more than 12 hours from the decision to admit to admission, an increase of over 10,000 from the previous month, which is a key indicator of patient flow through the health and care system.

7.       To address this, some integrated care systems (ICSs) have been supporting collaboration across health and social care partners to reduce the number of delayed discharges. For example, health and social care partners across Coventry and Warwickshire ICS have been working together to improve timely access to intermediate care services upon discharge from hospital. The team have developed a Community Recovery Service, made up of domiciliary care workers and allied health professionals from South Warwickshire University NHS Foundation Trust, to deliver intermediate care to those who need it. The package of care is provided and paid for by the NHS (via the Better Care Fund) for up to six weeks. This is expected to reduce length of stay in acute hospitals and allow people to receive the care they need in the right place.

8.       Although trust leaders across the country are developing innovative ways of working with the social care sector to alleviate pressure across the health and care system, more support is needed at a national level to put the sector on a sustainable footing.

9.       Our State of the Provider Sector report shows that nearly three quarters of trusts think it is either unlikely or highly unlikely that the NHS can meet the constitutional standards over the next five years.

10.   When asked what the government needs to do to enable trusts and systems to achieve this goal, a number of respondents stated that sustainable and recurrent investment in social care is vital to boost capacity in the sector which will, in turn, alleviate pressure on the wider health and care system.

11.   Trust leaders argue that investing in social care capacity is key to supporting the NHS as it would help to reduce delayed discharges, therefore freeing up hospital beds, reducing 12-hour trolley waits, handover delays, and improving patient outcomes and experience.

12.   As well as alleviating pressure on an already stretched NHS, improved access to social care supports the prevention agenda by enabling people to stay well and independent in the community.

13.   It is therefore clear that the cost of inaction on social care reform is significant for both patients and the NHS.

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?  

14.   Trust leaders are clear that pressures within the social care sector can limit the effectiveness of integration across health and social care at a system level, to the detriment of patients and the public.

15.   Trusts have been working hard to collaborate with system partners to deliver more integrated, holistic care at place level through place-based partnerships and more locally through integrated neighbourhood teams (as per recommendations made in the Fuller stocktake). However, trust leaders often cite a lack of capacity in social care as a key barrier to scaling up and expanding the delivery of integrated services via multi-disciplinary teams.

16.   Delivering the government’s shift from hospital to community and from treatment to prevention will also be hindered by the lack of meaningful reform in adult social care. Without a sustainable social care sector, people cannot receive the care and support they need to remain well and independent in the community. This results in unmet need and contributes to unnecessary hospital admissions.

17.   Trusts’ efforts to deliver consistent intermediate care and reablement services are also impacted by pressures in social care. The current provision of intermediate care varies across the country, resulting in a postcode lottery for patients. Adequate resourcing, across the NHS and social care, is needed to ensure all patients can access intermediate care and reablement services, which are vital to recovery and reducing longer-term care needs, in an effective and timely way.

18.   A lack of capacity in social care is also contributing to delayed eligibility assessments and fewer people being assessed as eligible for Continuing Healthcare (CHC). CHC is a ‘package of health and social care provided outside of hospital which is arranged and funded by the NHS’ for people with a primary health need. Insufficient funding and resource within the social care sector means fewer people can be supported through CHC, which risks patients going without the care they need or having to take on the financial burden of paying for care.

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

19.   As described in question one, the cost of inaction on adult social care reform is clearly highlighted by the number of people remaining in hospital each day who do not need to be there. The impact of this is felt not only by the patients themselves but across other parts of the health and care system too, including in ambulance services and emergency departments.

20.   It is important to note that the cost of inaction on social care reform is not confined to the issue of delayed discharge and patient flow. It also impacts NHS care delivered in the community, including mental health and community services, where integration with social care is vital and where demand and acuity of patient and service user need is rising.

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

21.   A recent report by Skills for Care estimates that the social care sector contributes £68.1 billion gross value added per annum to the economy in England (up 13.2% from 2022/23). The economic contribution includes private sector profits, indirect effects and induced effects.

22.   Reflecting this, social care should be seen as an investment rather than a cost. According to analysis by the Future Social Care Coalition, economic inactivity is one of the biggest problems facing the UK, and is in part being driven by high rates of people (predominantly aged between 50-64) who are delivering unpaid care for loved ones or suffer from long-term sickness/disability.

23.   Investing in the social care sector could therefore provide further economic benefit and help unlock further potential in the labour market by supporting people to stay in paid employment (both care users and unpaid carers), promoting financial independence and reducing the burden on the welfare system.  

24.   Limited social care provision places additional burden on the millions of people who dedicate their lives to caring for loved ones, with minimal support or recognition for the vital work they do as an unpaid carer. Although many carers derive a great sense of satisfaction and pride from their roles, it can significantly impact their ability to pursue paid work and can impact their mental health and wellbeing.

December 2024