Written evidence submitted by Norfolk Care Association [ASC 020]

The Housing, Communities and Local Government Committee has launched an inquiry on the long term funding of adult social care.

This inquiry will focus on how adult social care should be funded in the long-term. The Committee aims to understand the extent to which the Covid-19 pandemic has changed the landscape for long-term funding reform since we published recommendations on the subject together with the Health and Social Care Committee in 2018. The inquiry will consider how additional funds for adult social care can be raised, and how the adult social care market can be improved.  You can submit evidence until Friday 16 April 2021.

The Committee is inviting submissions primarily focussing on the following points:

1)      How has Covid-19 changed the landscape for long-term funding reform of the adult social care sector?

COVID-19 has raised the profile of social care in the public eye, its importance for those most vulnerable in our society and has emphasised the connectivity between the different parts of our social support systems.  Social care and good quality housing are the bedrock of the NHS.  Without good housing and a sustainable, high quality social care system the NHS cannot function effectively.

People live well and independently when support is available early on and interventions are planned as far ahead as possible.  However, in recent years, savings targets, increased life expectancy and the growth in numbers living with multiple and complex conditions have put a considerable strain on resources.  It has also meant that health and social care services will often only become involved after a crisis is reached and there is often an over-reliance on informal care.

We are living longer and medical advances and improvements in public health mean more of us survive what might otherwise have been terminal illnesses or life shortening conditions.  Going forward more people with a mix of physical and mental health problems will be supported in the community rather than in residential homes or specialist hospitals.

Shorter acute, mental health and community hospital stays are only possible if there is immediate access to the care and support needed by people following a hospital admission. Agile, social care services, able to respond flexibly in times of emergency, and the provision of 24-hour cover are part of the solution as is increasing the use of technology to monitor and identify deterioration in an individual’s condition and to prompt early intervention. 

All of this means that the social care workforce (paid and unpaid) is increasingly supporting people with multi-faceted and complex physical and mental health needs that can change on a weekly or daily basis. 

COVID-19 has located social care centre-stage as an integral part of the health and care system but, at the same time, it has highlighted the disparity between NHS funding and support and that for social care. 

Since March 2020, the world has been turned upside down by attempts to mitigate the effect of Coronavirus and reduce the infection rate. 

Where we had relatively full employment we now face the devastation of retail, hospitality, leisure and catering sectors. 

The damage inflicted will impact unequally with some groups of people much worse off.  Young people are especially at risk.

Social care providers have been a vital line of defence in dealing with COVID-19 outbreaks.   However this has come at a cost.  In some parts of the sector, business volumes have massively reduced.  Day Service providers have only been able to operate at basic levels and been dependent on subsidy for their continued existence.   Care and nursing homes have seen occupancy levels fall where there has been an actual or suspected outbreak.  Even where the customer base has not declined, business resilience for everyone continues to be tested severely as providers struggle to make ends meet with rising costs imposed by infection control measures, testing regimes, PPE and staffing systems.

The expectation that care staff do not work across different care locations diminishes the staffing flexibility in the care sector.  Staffing shortages and the use of “unfamiliar staff”, often from agencies, can impact negatively on quality of care delivered. 

Expectations on providers have also increased with more limited contact with other services, an increasing reliance on video consultations and reduced family contact for residents.  The loss of community resources and day services, for example, puts extra demands on care businesses to deliver additional recreational activities.   The possibility of provider failure increases the longer the COVID risk remains and social care worker fatigue and mental health support remain high level concerns.

We cannot say for certain how the demand for social care will change because of public perception of risk.  But it is likely there will be an increase in demand for more community-based care.   A rapid increase may create significant challenges for providers trying to adjust their business models.  Equally the reduction in capacity or loss of many face to face community and day services necessitates a re-think around how such services might be delivered in the future and there are concerns around social isolation, wellbeing and mental health for our most vulnerable residents, their families and carers if they lose access to such provision.

In the COVID-19 period, all businesses had to adjust to working with additional costs (i.e. equipment, testing, infection control measures, PPE, staffing rotas) and lower income.  Whilst many have been protected to some extent by government support, this is short term and subject to ongoing review creating considerable uncertainty within the sector.  The extra time and costs associated with infection prevention - donning and doffing, cleaning touch points, social distancing, visitor admin, testing etc are likely to remain in a post pandemic world, continuing to reduce direct care time.  This needs to be recognised and appropriately compensated.

Concerns for wellbeing of staff, volunteers and carers and the additional measures put in place to mitigate the impact of the pandemic on mental health have also added to the demands on providers as good employers.  The combination of higher level need amongst social care service users, more complex recording systems (eg oximeters), training and updates in infection prevention and control has put pressure on both providers and care workers.  And the staffing situation has been compounded by restrictions on staff movement to help prevent virus transmission and lack of a reservist or system-wide bank workforce (unlike the NHS).

Providers have had to change their environments to accommodate new regimes for testing and visitors and incurred additional expenditure to do so in the face of uncertain and, potentially, non-recurrent funding.   Business resilience has been tested to the limit.

Similarly, care workers have had to learn knew skills and pick up greater levels of responsibility whilst continuing to be paid less than their counterparts in statutory and NHS services.

While many of these concerns and inequalities have been aired over decades, COVID-19 has reinforced the urgent need for resolution.

2)      How should additional funds for the adult social care sector be raised?

The question as to the basis of social care funding needs to be considered first.  Healthcare is free at the point of need.  NorCA would argue that social care should be funded on the same basis:  a universal service free to all who need it and funded – as with the NHS – from central taxation/national insurance contributions.

If the current system of means and thresholds is to continue, then the same principles still apply.  Social Care funding should not be dependent on local authority priorities.  Recipients of social care services should not be dependent on a postcode lottery.  If the 2014 Care Act is to have meaning then as a national system, it should be nationally funded.

3)      How can the adult social care market be stabilised?

A sustainable and vibrant provider market delivering high quality care needs confidence in supply.  It also needs reassurance that the commissioned rate accurately reflects the cost of care being commissioned and allows for service and infrastructure development as part of those costs.

The assessment process, the funding formula for cost of care and the commissioning/contracting process need to be transparent.  And the commissioning should be outcomes based and not task focused in line with the vision of the 2014 Care Act.

Where there are environmental challenges (rurality/transport distances/specific needs/availability of staff/) there should be discretion for individual negotiation and amendment to standard contracts.

At the same time the adult social care market needs flexibility to move between different types of provision without over-burdensome regulation and bureaucracy and should be incentivised to offer unique and innovative solutions to intractable problems.  We need to start thinking more about commissioning whole life services that allow the mix of independence, care and support to change in line with the needs of the individual.

A national pay framework that addresses the disparity in pay, job security and terms and conditions amongst those working for the NHS, the local authority and independent providers would help to stabilise the workforce, reduce churn and aid retention.

4)      How can the adult social care market be incentivised to compete on quality and/or innovation?

There are three elements to our response.  The first is around a culture of trust and transparency between commissioners and providers and in the commissioning process.  This culture would include a genuine and proven receptiveness to ideas and innovations and a desire to co-produce new models of care.

The second is around what is commissioned (ie outcomes, not activity) and the criteria/weighting used to give providers an opportunity and incentive to be creative.

The third is that we cannot escape the fact that social care is and has been for many years underfunded.  Good quality care will not be possible at any price.

Finally it is important that mixed messages are not inadvertently sent.  If ‘quality is king’ then those that that deliver quality (however this is measured) should be rewarded.  A provider rated outstanding should be clear how their hard work to achieve great standards is being recognised.

April 2021