Written evidence submitted by Care England [ASC 018]
Who are we?
Care England is the adult social care sector’s largest representative body. Our members run and manage approximately 4,000 care services, amongst them single care homes, small local groups, national provider and not-for-profit voluntary organisations and associations, as well as private providers. Members provide over 120,000 beds and various services for older people and those with long-term conditions, learning disabilities and mental health problems.
The adult social care sector comprises a vast range of charitable and independent services that deliver support, care, and healthcare for vast swathes of the UK’s population. While the contribution to society is immeasurable, in economic terms, the sector accounts for:
We estimate that the sector’s role in the UK economy is set to grow both as a consequence of an ageing population and, in the short term, owing to rising unemployment in other parts of the economy. A recent report by the Low Pay Commission stated that just 10% of the adult social care workforce has been furloughed, demonstrating the sector’s importance in responding to the COVID-19 pandemic. Whilst Skills for Care stated that “if the adult social care workforce grows proportionally to the projected number of people aged 65 and over in the population then the number of adult social care jobs will increase by 32% (520,000 jobs) to around 2.17 million jobs by 2035.”
We welcome the Housing, Communities and Local Government Committee’s enquiry into how social care should be funded in the long term. For too long, adult social care has been neglected, as evidenced by the multiple studies cited within our full submission. This has led to the production of an adult social care system with many dysfunctionalities. In particular, the commissioning of adult social care has not received enough attention. Something which has led to the entrenchment of commissioning practices which, in many parts of England, serve to undermine rather than enhance provider sustainability, for example:
We hope that the Housing, Communities and Local Government Committee’s regulatory and reputational teeth has the potential to, instead, encourage commissioning processes that support provider sustainability. This will be key in the riddance of the plethora of negative externalities produced by a scarce funding reality. This, too, has the potential to contribute positively to the production of an adult social care sector which is event better place to:
It is our view that the Covid-19 pandemic has illustrated the contribution that adult social care makes to England’s society, economy, and communities. In turn, we would like to state our support for the Health and Social Care Committee’s call for an annual £7 billion increase in social care funding as a starting point for reform.
However, our submission seeks to point out that extra funding alone will not remedy the adult social care system. Instead, the culture, processes, and attitudes of many LAs and CCGs are themselves geared against commissioning, reflecting the cost of care in their local areas. In turn, we would suggest the following policy areas to be considered as part of funding reform, including:
The 2019 Conservative Manifesto laid out the Government’s commitment to forging “a long-term solution for adult social care.” However, at present, this commitment is yet to materialise. Over the coming months, we sincerely hope that the Government takes the opportunity it still has to reform adult social care positively. For, if anything, the COVID-19 pandemic has illustrated the importance of adult social care’s contribution to England’s economy, society and communities.
We thank the Committee for continuing to shed light on the long term funding of adult social care. For, if anything, the Covid-19 pandemic has accentuated the importance of creating a funding reality that supports rather than undermine the adult social care sector’s development. For too long, commissioners have proved unresponsive to the needs of the sector.
We concur with the Health and Social Care Committee’s call for an annual £7 billion increase in social care funding as a starting point for reform. For sufficient funding is fundamental in creating a system that supports reform. Rather than merely focusing upon survival, a reality that does not allow providers and commissioners alike to focus on reform and system change. Sufficient funding is also fundamental in supporting the implementation of those reforms cited in the NHS White Paper.
Any future strategy must, however, take a holistic approach towards the long-term development of adult social care, including:
Care England’s vision for social care:
This new vision should be about moving from a crisis orientated system to one that is asset-based and maintains the choice, autonomy and control for people as much as possible. It must also deliver services that are connected to the heart of local communities. Whilst individuals and families should be more responsible for commissioning the services that positively impact their lives.
The diversity of the population and the multiplicity of needs means that no particular form of social care should be prescribed. All current and new approaches should be considered valuable, so long they deliver the outcomes that the citizens require and give value to society. For example, care homes are an essential part of the continuum of care, and policy must not be driven by dogma but rather by choice. Social care cannot be detached from other aspects of policy, and we need to understand the interdependence between health and social care, housing and transport, etc.
Providers, too, must be responsive to the changing needs of the population. For example, adapting the services which they offer based on changes in societal taste. However, their ability to do so is very much contingent on sufficient funding. Insufficient funding has the potential to undermine innovation. Despite this, an entrepreneurial culture has the potential to emerge in a context of scarcity. One example of provider innovation being the utilisation of spaces for day services that have become available as a result of decreased activity on the high street.
Local Authority Fee Rates:
Care England is of the view that the present commissioning system is not fit for purpose. Too often, publicly funded care is underfunded, and fee increases are made with little consideration of the true cost of care. Despite the Covid-19 pandemic, care providers continue to be offered fee rates that undermine rather than enhancing provider sustainability. Care England, has, already this year, been made aware of rates that do not take sufficient account of provider expenditure. Below are but a few of the offers that have been received by providers from LAs thus far this year:
With reform, we sincerely hope that this reality will change to one which is reflective of the true cost of care. In April, the National Living Wage rate is scheduled to increase by 2.2%; in turn, many of the fee increases cited above do not even account for this increase. Whilst many of the poor fee offers made above are made on top of endemically low fees.
In turn, Care England very much welcomes the proposal in the White Paper for “a new duty for the Care Quality Commission (CQC) to assess local authorities’ (LAs) delivery of their adult social care duties.” However, again, there is a lack of clarity regarding how such a system may work in practice. Such technicalities will be pivotal in ensuring that LAs do not continue with commissioning processes that undermine, rather than enhance, provider sustainability. Otherwise, we fear this scheme will fail because it does not have the requisite regulatory teeth. This is based on the fact that Care England has been confronted by intransigence on the part of LAs who refuse to reform their commissioning practices for many years.
Endemically low fee rates in many areas of the country produce a plethora of adverse externalities, including:
Going forward, we would also encourage MPs to do more to support the provision of commensurate fee levels.
Continuing Healthcare Rates:
Similarly, when it comes to the commissioning of CHC rates, many CCGs fail to take appropriate account of the true cost of care. Instead, many care providers tell us that CCGs do not make enquiries into what care costs. Whilst many CCGs have been extremely poor at collaborating with providers during the Covid-19 pandemic. Care England is currently liaising with NHS England regarding those CCGs, which, we believe, need more effective commissioning processes.
There is an alarming trend of disengagement in their treatment of their local care markets. The manifestations of this disengagement, combined with other pressures, are driving instability in the market, which, if not addressed, will see a crisis in the availability of nursing service provision within care homes. Providers continue to be frustrated by the number of CCGs that remain unwilling to engage with them in any or any meaningful negotiations on Local Prices for CHC.
The lack of accountability within the current system:
A recent National Audit Office report stated that “The Department acknowledges that most local authorities pay care providers below a sustainable rate but does not use this analysis to challenge local authorities directly.” The lack of action identified by the NAO’s report is a testament to the failure of the DHSC to effectively oversee the market. It is also a testament to the indifference with which the adult social care sector has been treated by parties of all stripes.
However, their inability to influence the market is also, perhaps, a testament to the innate dysfunctionalities associated with localised forms of funding. This has too been seen during the pandemic when one considers the passing on of those support funds from the DHSC to LAs to care providers. Throughout the pandemic, many providers have stated that such support funds have been passed on in a cumbersome and inefficient manner. Take, for example, the £1.55 unringfenced grant for LAs, which the DHSC suggested could be used to support adult social care occupancy and increase insurance premium. However, at present, there is little sign of this materialising and Care England has largely heard reports that this has merely been subsumed into other parts of council budgets.
Whilst, when it comes to CCGs, neither the NHS nor the DHSC has the requisite power to impact the processes and cultures of CCGs. From our point of view, CCGs very much operate as their own independent entities, meaning that they are often unresponsive to the needs or calls of the adult social care sector. This has been reflected during the pandemic, where providers have consistently told us that they were not given the requisite support by CCGs to deal with the costs associated with the Covid-19 pandemic. Going forward, we therefore sincerely hope that the NHS White Paper leads to the fostering of a system of CHC commissioning that supports independent care sector provider sustainability.
For many adult social care providers, the COVID-19 pandemic has wholly altered the nature of the operating model and costs associated with the delivery of care. For example, this has been seen in the case of care homes nurses and other staff members who now fulfil a plethora of new roles and responsibilities (see appendix A). Many of which will persist in the future and care homes are likely to have to maintain their new model based on infection control for the foreseeable future. More broadly, other costs for the sector have included:
Whilst, in many areas, Covid-19 has impacted the occupancy rates of adult social care home providers. Some providers have experienced unparalleled drops in occupancy levels which some believe are likely to stretch into the medium and longer-term. For example, a recent report by the West Midlands Capacity Tracker stated that “There are 36,366 occupied beds and 9,259 vacancies, with average occupancy remaining low at 79.7%. Occupancy is highest in Telford & Wrekin homes (83.9%) and lowest in Solihull (65.9%).” Whilst a Care England member stated the following:
“From all the discussions I have had, everything has been done without ANY thought to occupancy rates – this has been the case for years as all LA’s are concerned about is minimising their per placement costs.”
This has been a result of both reduced admissions, but also, higher death rates amongst adult social care users. As a consequence, social care providers base costs have increased substantially. Decreased occupancy rates have, in turn, increased care costs per head. Therefore, future fee rates need to take account of such realities. Thus far, many of the fee offers made by LAs have wrongly been based upon pre-pandemic occupancy levels. This is emblematic of the failure of LA commissioning to react to the new realities imposed upon the sector, not only during the pandemic, but also, more broadly.
Whilst we, too, have called for the DHSC to implement an occupancy strategy to stabilise the care sector, however, as of yet, this has not been acted upon. Similarly, the £1.55 billion grant for LAs, which the DHSC suggested could support providers through low occupancy levels, we fear will not make its way to the frontline, and much will be subsumed into other parts of council budgets.
Market Position Statements:
According to Think Local Act Personal a Market Position Statement is intended to do the following:
Carried out by LAs there does exist many good examples within the adult social care sector. However, at the same time, many of our members have involved Care England that some commissioning LAs fail to formulate Market Position Statements in an effective manner. Instead, we have received feedback that some LAs do not always consult with their local market to a satisfactory extend.
Transparency of fee rates:
Through our campaigning, Care England has been made aware of the lack of transparency which exists when it comes to LA fees. Instead, many LA websites prove extremely difficult to navigate, especially when it comes to identifying yearly fee rates. This has forced Care England to send off yearly Freedom of Information Requests, rather than simply being able to extract such information from LA websites. In turn, we would call for greater standardisation in terms of how fees are shared publicly. This would hopefully generate greater scrutiny of poor fee rates and make a broader cohort of people aware of the plight faced by many withing the care sector.
Workforce funding and resilience:
The adult social care workforce is our biggest resource. Before the pandemic, it faced many adverse trends, including absenteeism, recruitment, retention and turnover. COVID-19 has made some of these issues even more acute in the short term. Out of all of the hardship which has stemmed from COVID-19, there needs to be a positive trend towards professionalisation and reward in the adult social care sector.
Whilst the workforce is resilient, it is only as resilient as the funding and support behind it hence the need for adequate long-term support for the sector. For too long, an increasing cohort of adult social care service users has been supported through a smaller pot of government funding. In turn, this has an inevitable consequence for the nature of some employment opportunities within the sector.
We have, therefore, been disappointed by the failure of the Government to reward adult social care workers for their service during the pandemic. Despite multiple calls from Care England and the sector at large, it is yet to implement a bonus scheme like those implement in Wales and Scotland.
Changing needs of the population:
At present, it is impossible to understand, in full terms, the impact which Covid-19 has had upon England’s population. However, anecdotally, Care England members have told us that many of those who are being admitted to care homes have much higher need levels. This is perhaps a ramification of the decreased activity levels which Covid-19 has imposed upon the adult social care population. Any future funding system must, therefore, take sufficient account of the impact which Covid-19 has had upon the needs base of England’s population. We believe that further research needs to be commissioned to take sufficient account of this.
Prior to the pandemic, it was well known that adult social care was afflicted by a funding gap. For example, “the Health and Social Care Committee provided a table setting out different organisations’ estimates of the adult social care funding gap. The estimates, which did not take account of the additional costs created by the Covid-19 pandemic, ranged from £1.4bn per annum to £12.2 billion per annum.” However, The Health Foundation’s recent report suggested that Covid-19 has produced a number of uncertainties in relation to the funding gap, including:
Long term demographic change:
The UK population is growing in size, and people are living longer. ONS data suggests that the number of adults aged 85 or over, the age group most likely to need care, are rising faster than the population as a whole; the overall UK adult population grew by 7% between 2009 and 2019, while the number aged 85 or over rose by 23% in the same period.
The number of people living with a learning disability in the UK is increasing. Combined with demographic factors, this has increased the demand for care; the number of adults with learning disabilities receiving some form of long-term social care, which increased by 8,360 people from 139,555 in the period 2014 to 2015 to 147,915 in 2017 to 2018.
Indeed, increased life expectancy and an increasing proportion of people living to older ages with complex needs have increased pressure on care systems and the funding that supports them. On average, across the OECD, it is expected that public long-term care expenditures will increases as a proportion of GDP, from 0.8% in 2010 to 1.6% in 2060. Funding arrangements are key to all aspects of the performance of long-term care systems.
Overall, this clearly accentuates the importance of creating adult social care markets that take account of such long-term trends. For too long, adult social care commissioning has been merely based upon short-term thinking which is partially a result of the underfunding that remains apparent within the adult social care system. Similarly, the creation of effective and changing adult social care markets will be essential in allowing England to respond to the changing demographic need of its population.
Long term employment:
The COVID-19 pandemic has and will inevitably continue to have an adverse impact on employment in England. Something which was recently confirmed by the Bank of England’s February report which stated that “A further increase in unemployment is projected over the next few quarters.” Whilst many parts of the economy are not expected to recover to pre-COVID levels.
Any future Government strategy must therefore play sufficient dues to the role which adult social care has to play in providing meaningful long-term employment. For example, the Resolution Foundation calculated that it would cost £1.4 billion pounds to ensure that all care staff are paid the Real Living Wage. Such views have been echoed by the likes of the TUC, both of whom see adult social care as a growth area for employment in the coming months and years.
Similarly, adult social care will be of fundamental importance in England’s return to somewhat of a ‘normal’ economy. A report from Carers UK noted how the COVID-19 pandemic had impacted the caring responsibilities of many within England. It states that “the pandemic has resulted in millions of new carers – 4.5 million new to caring since the start of the pandemic, 2.8 million of whom are juggling work and care.” Those individuals who are informal carers are also likely to be less economically active or unemployed. Therefore, adult social care will be of importance in allowing new carers to return to the workforce. Similarly, the resumption of ‘normal’ adult social care referral levels to adult social care services will reduce the risk of individuals withdrawing from the workforce.
In addition, the role of the adult social care sector to provide quality employment has the potential to become even greater. However, this will be contingent upon its ability to respond to the employment needs of the 21st century. One aspect is that employers should look to increase work flexibility by, for example, relocating adult social care workers who are struggling with the physically demanding aspects of the work into more relationship-based care. Such steps may assist in creating greater value within the adult social care workforce which will likely lend itself to greater levels of retention; evidence suggests that care workers whose work is valued and appreciated have higher levels of job satisfaction and are more likely to remain in their jobs.
Overall, we would, therefore, urge the Government to fund the adult social care sector in a sustainable manner to enable it to establish:
In turn, the Government needs to commit to the publication of a workforce strategy that establishes its thoughts around how this can be enacted. An adult social care market and commissioning processes which support the development of a more positive employment reality is, therefore, more crucial than ever. For too long, commissioners have commissioned care at rates which do not take sufficient account of the workforce implications involved.
Similarly, the Low Pay Commission’s recommendations in relation to wages have not been matched by adequate government funding to allow the adult social care sector to implement such recommendations in a sustainable manner. This has, in fact, led to an array of negative effects, including how it has led to some social care providers having to decrease wage differentials and in turn their capacity to reward their most experienced staff. Thus, the unnuanced nature of the National Living Wage’s delivery cannot persist. Similarly, the latest, very low FNC offer by the DHSC has the potential to undermine adult social care nurses getting the recompense they deserve.
Lastly, we welcome the DHSC’s Adult Social Care recruitment campaign and hope this campaign continues into the future as it is a key tool in shaping the public’s interpretation of the sector.
Hospital discharge routes:
The adult social care has a really central role to play in facilitating hospital discharge and freeing up space within the health system. Going forward, it is, therefore, essential that such routes are appropriately funded. For, these routes are essential in promoting the independence and recover of those whom have been in hospital. Whilst there is a need for longer term planning for the development of such systems.
Integrated care systems (ICSs) and adult social care:
It is of fundamental importance that the adult social care sector’s voice is heard in the discussion on how ICSs are set up. At present, we are troubled by the fact that, for example:
At present, many providers feel that their local systems are not collaborative enough in nature. In turn, we sincerely hope that the above questions are considered and adult social care’s voice is incorporated into the future health and care landscape.
Long-term funding gap:
Many of the dysfunctionalities outlined above and associated with the adult social care market are deeply intertwined with the long-term funding gap, which is well documented. Therefore, we would restate our support for the Health and Social Care Committee’s call for an annual £7 billion increase in social care funding as a starting point for reform. The pressures of dwindling government resources and increasing needs for an ageing population make the current Pay as You Go funding arrangements impossible to sustain in the future. We have called for the NHS White Paper to make a commitment to set up a sustainable funding solution.
Overall, Care England has sought to stress that Covid-19 has imposed a new reality upon the adult social care sector. However, existing funding and commissioning models have, thus far, proved incapable of responding to it. Going forward, a commissioning system needs to be created that is responsive to the needs of the adult social care sector, both in terms of CHC and LA funded rates.
In addition, we have sought to evidence the how the creation of effective adult social care markets is fundamentally intertwined with the sector’s ability to respond to the future demographic and employment needs of England’s population. For too long, adult social care commissioning has, in many parts of England, served to merely undermine provider sustainability and ingenuity.
Appendix A: Increased nursing tasks as a result of COVID-19
 The economic value of the adult social care sector – UK (skillsforcare.org.uk)
 OGUK Economic Report 2019 (ofgem.gov.uk)
 National Minimum Wage (publishing.service.gov.uk)
 The size and structure of the adult social care sector and workforce in England (skillsforcare.org.uk)
 MPs call for £7bn annual increase in social care funding as a starting point for reform – doing nothing ‘no longer an option’ - Committees - UK Parliament
 Conservative 2019 Manifesto.pdf
 MPs call for £7bn annual increase in social care funding as a starting point for reform – doing nothing ‘no longer an option’ - Committees - UK Parliament
 Integration and innovation: working together to improve health and social care for all (HTML version) - GOV.UK (www.gov.uk)
 The adult social care market in England - National Audit Office (NAO) Report
 The Government Response to the Health and Social Care Committee report on Adult Social Care: Funding and Workforce (parliament.uk)
 Light at the end of the tunnel: Occupancy could return to pre-pandemic levels by Nov 2021 - Carterwood, improve decision making
 Market Position Statements - In more detail - Commissioning & market shaping - Co-production in commissioning tool - Think Local Act Personal
 CBP-7903 (1).pdf
 Social care funding gap | The Health Foundation
 GOV.UK (2019). People with learning disabilities in England. Public Health England. Available at: https://www.gov.uk/government/publications/people- with-learning-disabilities-in-england
 Bank of England Monetary Policy Report February 2021
 Social Care: Funding and Workforce (parliament.uk)
 congress jobs story_report.pdf (tuc.org.uk)
 A Recovery Plan for carers - Carers UK