Written evidence submitted by NHS Frimley ICB (ASC0133)

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?  

The lack of reform and investment in social care disadvantages the social care system, the ability that people must engage in their own health and wellbeing and has a wider impact on the health sector. The key impacts of how inaction on adult social care reform is directly affecting patients and the public (as well as the NHS and local authorities) include:

• Unmet/evolving need for social care – a growing gap between the demand for services and their availability (e.g. occupational therapy and autism assessments).
• Workforce challenges – recruitment and retention remain a critical issue (e.g. due to pay and working conditions) and such issues amplify the challenges associated with sufficient social care services.
• Wider system pressures – pressures on acute services increase because of insufficient social care services capacity and the impact
• Adult social care funding – reduced and underfunding funding means many councils find it difficult to meet their statutory duties and are redesigning their offer. This results in, for example, lower service quality and workforce challenges like high turnover and shortages as well as inconsistent quality across geographies.
• Waiting times – Demand that is higher than the capacity that is available is leading to longer waiting times and/or some placements that are not into registered setting. This can put pressure on both NHS services in the community and in supporting discharge and flow within hospital settings (acute, mental health and community)
• Avoidable pressure on families – families and other (unpaid) caregivers that need to fill the gaps in the social care system end up experiencing a strain on their time, finances, and wellbeing. This in turn put additional strain on the NHS when the pressure impacts on carer health (physical and mental)
• Health disparities – inadequate investment/variable levels of reserves contribute to worse patient outcomes and inequalities, particularly in rural and economically disadvantaged areas. Variation in adult social care financial positions adds to complexity for health and care pathways when health partners are working with a range of adult social care authorities
• Post-hospital stay care – hospital discharge delays might result from insufficient resources in social care, such as a lack of available care home beds and home-based care services that are critical to supporting patients after their hospital stay. Vacancies with assessment and placement teams have an impact on flow, decision making and partnership working as well as the head space to this strategically about the future. It should be noted that adult social care processes are only a small part of the overall challenges in reducing the unwarranted time individuals are spending in hospital settings
• Rehabilitation and reablement – adult social care teams include intermediate services that are key in supporting people to remain independent in their own homes and return in a timely way from hospital. Available funding is affecting both the ability to recruit and the amount invested in this area. In turn this means more people’s needs are being escalated to the point that they need NHS intervention and bedded care.

What NHS and local authority service reforms are not happening because of adult social care pressures, and what benefits are patients and the public missing?  

Adult social care pressures are preventing NHS and local authority reforms, and impeding benefits patients and the public that, include:

NHS and Local Authority service reforms not happening:

• Health and social care provider integration – reduced and underfunding of adult social care makes it harder to integrate health and social care services. Therefore, care pathways are often fragmented and patient transitions between hospital and community care are poor.
• Health and social care commissioning integration – joint strategic commissioning capacity is being impacted by lack of adult social care capacity available to step back from operational management and jointly plan.
• Efficient hospital discharge processes – staffing pressures/vacancies, underinvestment in the right kind of care home beds and home-based care affects a proportion of hospital discharges with people being managed in the wrong location and the capacity of the NHS to treat new patients in acute care. The pressure this creates in acute hospital also leads to some people being discharged prematurely into bedded care when taking slightly more time to put in place home based care packages may have resulted in a better solution for the individual, family and in the longer-term public-sector resources
• Workforce strategies – a robust workforce strategy is required to improve staff recruitment, training, and retention. An integrated workforce strategy for NHS and local authority services (i.e. joint planning) as well as other organisations could target, for example, career pathways.
• Workforce flexibilities – differential pay and conditions between the NHS and LAs for similar roles impacts on the ability to create integrated teams, provided career paths that move easily between health and care settings
• Preventative care and independent support –underfunding means it’s difficult to develop preventative services (e.g. social prescribing and reablement programmes and services) that could help to avoid hospital admissions.

Benefits patients and the public are missing out on:

• Integrated services and smoother transitions – appropriately funding social care services that emphasised joint working, including preventative care, would help patients transition between care settings. This would help to
• Reduce the pressure on NHS resources.
• Patients experiencing fewer health crises, faster recovery times, and better overall well-being.
• More equitable access to care and services regardless of location, socioeconomic status, and need (e.g. autism).
• Better quality of life (e.g. through greater independence) including for carers and family members.

• Safeguarding for vulnerable people – implementing reforms like the Liberty Protection Safeguards to ensure people have the proper legal protections.
• Complex care needs – ensure there is enough capacity for services like occupational therapy, supported living, mental health and learning disabilities leaves many underserved. Long waits or inappropriate placements are common.
  

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

Costs of inaction to individuals:

• Unmet care needs – if social care providers reduce their services and/or withdraw contracts (e.g. due to insufficient funding) contribute to a growing gap between the demand for services and their availability (e.g. occupational therapy and autism assessments) affecting patient health, well-being, and quality of life.
• Economic and employment – fewer services or services without investment limit job opportunities for carers and working-age adults with care needs. In turn this would affect their earnings, reduce family income, and stunt community prosperity.
• Avoidable pressure on families – families and other (unpaid) caregivers that need to fill the gaps in the social care system end up experiencing a strain on their time, finances, and wellbeing (e.g. as they try to balance their responsibilities with work and personal health).
• Deteriorating health – health crises, and the need for additional treatment later, can be avoided if care isn’t delayed or inappropriate care isn’t provided.
• Health disparities – underinvestment contribute to worse patient outcomes and inequalities, particularly in rural and economically disadvantaged areas. In some cases, this can lead to placement in distant or unsuitable care settings.
• Social isolation and reduced independence, including the ability to work – adult social care services are a critical support to individuals and their roles within communities.

How lives might change with action:

• Better life quality – better person-centred and community-based care would result in greater independence and wellbeing for carers and family members.

• Job opportunities – for carers and individuals presenting with care needs because of better employment opportunities, job prospects and well-being.
• Avoidable pressure on families – families and unpaid carers would benefit from (e.g. less stress and demands on their time and finances) with better training, pay, and support for social care workers.
• Health and wellbeing – preventative care and independent support would reduce health and avoid admissions while community-based models of care would promote greater independence and dignity.
• Health disparities – underinvestment contributes to poorer patient outcomes and inequalities, particularly in rural and economically disadvantaged areas.
• System support – targeting the impact of delayed discharges when and where they happen and access to and availability of community care through reform would reduce pressure in the system.
• More people of working age in employment – working with health to support people access quality employment opportunities
  

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

The cost of inaction on adult social care reform in an Integrated Care System is typically borne most heavily in the following areas:

1. NHS

• Increased admission rates: without sufficient social care services and resources, patients may face health deterioration and require more frequent or prolonged hospital admissions.
• Delayed discharges – without sufficient social care services and resources, patients that could be managed at home or in a care home can remain in an acute care setting for longer than necessary. Where this happens it reduces hospital capacity, leading to (I) longer waiting times; (II) emergency care delays; (III) greater pressure on staff; and (IV) rising healthcare costs.

2. Primary and community care

• Primary care services – primary care pressure grows as patients with unmet social care needs need to rely on GPs that become the first point of contact for individuals with social needs. Hence, the lack of appropriate social care worsens conditions that could be better managed or prevented with more appropriate care.
• Community-based services – home care, reablement, and domiciliary support are often underfunded or underdeveloped. As a result, many individuals are either not receiving the care they need or are relying on more expensive, hospital-based care. This also puts pressure on primary care and community care services/ongoing medical care.

3. Social care workforce

• Staff recruitment and retention – low pay, poor career progression, unfavourable working conditions mean it’s difficult to maintain a stable workforce. Reforms are needed to improve pay, training, and career development.
• Agency workers – care providers often rely on more expensive agency workers that could be better invested in building a stable, skilled workforce.

4. Local authority finances

• Local Authority Finances – commissioning high-quality, sustainable adult social care services and meeting financial responsibilities is difficult without further funding. This often forces local authorities to reduce or ration services, impacting the individuals that rely on them.
• Preventative services – underfunding means it’s often difficult for local authorities to invest in preventative services (e.g. home adaptations, early intervention programs, social prescribing, etc. are often delayed or deprioritised) that could otherwise reduce long-term care needs and costs to the system as well as and improve outcomes.

5. Health Inequalities and Population Health

• Health disparities – underinvestment contributes to poorer patient outcomes and inequalities, particularly in rural and economically disadvantaged or deprived areas and elderly people with disabilities. Again, the impacts include poorer health outcomes, increased hospital admissions, and higher long-term costs to the system. (ICSs will struggle to reduce health inequalities without a properly resourced social care system that ensures equitable service access.)
• Preventable health crises – without adequate social care services, individuals experience worsening chronic conditions or mental health crises, often leading to more urgent and expensive interventions, as well as long-term care dependencies that could have been avoided through earlier, more effective care.

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

Current contributions:

• Job creation and local economies – adult social care is an important employer, particularly for women and minority groups. It supports local economies, especially in areas with high demand for care services.
• Care home profitability and cost savings – higher occupancy rates and reduced agency staffing costs have contributed to better financial positions for some care homes while international recruitment schemes have helped alleviate workforce pressures.
• Activities support people maintaining their independence including ability to work – reducing overall cost of unemployment
• Carer support – reducing statutory services costs and enabling people to remain in their own homes/communities
• Signposting to community and voluntary services provision – releasing statutory agency capacity for those who most need these services

Reform benefits:

• Efficiency and economic returns –a reformed social care system could reduce inefficiencies, like discharge delays caused by inadequate care availability. This would free up NHS resources, improve patient flow, reduce costs​, etc.
• Workforce – better pay, career progression, and recognition for social care workers could help to address high recruitment and retention.
• New models of care – reform could enable providers to invest in new models of care, promoting prevention, independence and reducing long-term care needs.
• Stronger Integration – Effective collaboration between health and social care could reduce unnecessary hospital admissions and optimise general resource use, delivering economic benefits to HM Treasury​.
• Equality in Access and Contribution – addressing care disparities could unlock economic potential in underserved areas and ensure equitable access to services.

December 2024