Written evidence submitted by Surrey County Council [ASC 029]

1. Surrey County Council (SCC) welcomes the opportunity to submit evidence for this inquiry on the long-term funding of adult social care (ASC). This has long been an issue that governments have recognised needs addressing but been unable to develop satisfactory solutions. The Prime Minister has promised his government will be announcing proposals later this year and we will be engaging with ministers and officials over the shape and scope of them in the coming months. This inquiry is an opportunity to further inform the debate and we would welcome the chance to provide further oral evidence to the Committee.

Key recommendations

2. Government should use its upcoming green paper on adult social care (ASC) to set out a clear long-term funding model for ASC, moving away from short term funding announcements with no clarity about the permanence of funding which prevents local authorities from planning effectively for the long term.

3. ASC long-term funding reform must have a much greater focus on appropriately funding care and support for working age adults, especially those people with a learning disability, autism or a mental health problem, rather than focusing mainly on the funding model for older people which has often been the case in the past.

4. In developing its paper, government should ensure the ASC sector is treated as an equal partner in shaping this long-term funding model and policy objectives. The ASC sector must be part of the decision-making process, rather than being handed policies to implement, which often then do not work effectively on the ground.

5. Current funding for ASC and Public Health (e.g. Better Care Fund, improved Better Care Fund, core Public Health grant) should be sustained under the new funding model, while new funding provided should be genuinely additional to these allocations (i.e. it is essential the existing funding is not simply rebadged as “new” funding).

6. The government’s proposals should put prevention at the heart of any new funding model.

7. Do not route ASC funding through the NHS. The ASC sector recognises the benefits of working closely with NHS partners and this is already happening across the country. Funding allocations for ASC though should come straight to local authorities who are the experts in social care provision and have a very strong track record in tight fiscal stewardship.

8. Allow local authorities and their partners the flexibility to invest funding as dictated by local circumstances to achieve local objectives and national priorities. Do not set activity-based targets for increased funding with huge amounts of bureaucracy around reporting and monitoring which is very typical of NHS funding allocations. This stifles innovation and the ability to invest funding agilely.

How has COVID-19 changed the landscape for long-term funding reform of the ASC sector?

9. It is too early to fully judge many of the long-term impacts of the pandemic on the ASC sector, such as the demand for services as the country starts to move into of a recovery phase. Surrey County Council (SCC), however, would like to see the government take the following issues that have been highlighted during the COVID-19 crisis into account when shaping its proposals for long-term ASC funding reform.

10. ASC’s national profile has risen, and this must continue

The importance of the ASC sector in supporting the most vulnerable in society and in doing so relieving pressures on the NHS has been acutely demonstrated during the pandemic. ASC’s national profile has rightly increased. It is imperative that this is not lost as the pandemic begins to ease. The ASC sector must be treated as equal partners, working alongside the NHS in shaping the nation’s health and wellbeing priorities.

11. The ASC’s workforce challenges must be addressed

The pandemic has highlighted more than ever the importance of a well-trained and skilled ASC workforce. Infection control has quickly become embedded as part of the day-to-day working life for ASC staff and this will continue long into the future. The workforce challenges of the ASC sector are well documented, and Surrey is no different ; Low pay; challenging work now with heightened health risks; lack of job security; and, unlike in the NHS, often no clear career pathway due to the fragmented nature of care provision in the ASC sector. Long term funding reform for ASC must focus on increasing both the societal and financial value placed on the ASC profession.

12. Solving this, though, is far from straightforward. The government should work with local authorities and ASC providers to set clearer national standards for ASC caring roles, including minimum expectations for pay and clearer career pathways. Over time the aim should be for caring roles in the ASC sector to be seen and valued in a similar way to roles in the NHS. This will only be successful, however, if local authorities are funded sufficiently to meet higher workforce costs and crucially if there are mechanisms to ensure care workers benefit directly from the increased payments to ASC providers.

13. ASC should co-design policies with the NHS

Greater collaboration, joint working and where appropriate integration between the ASC sector and the NHS have long been national policy objectives. The ASC sector has demonstrated its ability to work very effectively with NHS partners during the pandemic. A clear example of this has been the implementation of the national Discharge to Assess (D2A) model introduced at the outset of the pandemic and then adjusted in September. At a time of intense pressure, the ASC sector has risen to the challenge working round the clock to discharge people promptly to improve patient flow and then conduct assessments to determine people’s ongoing funding responsibility generally within the nationally set timeframes.

14. These policies had to be developed and implemented at pace due to the seriousness of the pandemic, but SCC believes the ASC sector should be invited to shape the future of the D2A model and other key policy initiatives that involve joint working between health and social care. Partners from the ASC sector must have a seat at the table to ensure policies deliver outcomes that maximise people’s opportunity for independence, can be successfully implemented operationally on the ground and deliver value for money for the taxpayer.

15. The shift away from traditional models of care should continue to be accelerated

The pandemic has accelerated the shift away from traditional models of care. Like most local authorities, SCC is transforming its ASC services to embed a strength-based approach to social work practice that focuses on maximising people’s independence. This is less costly and better for people’s wellbeing and long-term life aspirations. A key aspect of this change is moving away from traditional institutionalised models of care, such as residential care homes and building based day care, to services that focus on helping people live as independently as possible in the community, such as independent supported living, shared lives and community outreach.

16. The pandemic has had a significant impact on all ASC service provision, but traditional building-based services have been especially affected. Care homes have sadly seen a substantial number of their residents die or be severely affected by the virus, and most day centres have been closed for large parts of the last year. Some families of working age adults have also chosen to bring their relatives home to minimise the risk of infection. Whilst the societal impacts of this must not be overlooked and should never be forgotten, it is equally important that the changes that the pandemic has accelerated are harnessed as an opportunity to engender a fundamental shift not only in the nature of social care provision, but also how society thinks about social care as a concept. Rather than thinking about care as a way of finding a safe place for people to receive support separate from normal day-to-day life, we must use the terrible events of the last year to change the conversation to one in which the wider community (individuals, families, friends, the third sector, local government, the NHS and central government) collectively focuses on how people can be supported to play as full a part in day-to-day life as possible.

17. SCC has its own ambitious plans to significantly expand services in the community including targeted reablement to help people recover quickly and regain their independence, extra care housing for older people, independent living for people with a learning disability or autism, shared lives for people with disabilities or mental health problems and a range of other community outreach services. It is essential that long term ASC funding reform is focused on expanding support in the community to enhance people’s independence rather than traditional models of care, whilst recognising there will continue to be a need for high quality provision in traditional models of care to support people with the most complex needs.

18. A key aspect of service innovation to change models of care is investment in new Technology Enabled Care Services (TECS) to allow remote health monitoring in peoples' homes and smart technology to enable some replacement of person-based support hours so that the ASC workforce is able to focus on the more skilled work.

19. Prevention is better than cure

For far too long the national funding model for health and social care has focused on addressing the symptoms of the nation’s health and wellbeing challenges rather than the causes. Public health spending was already well below where it needed to be when the responsibility for these services transferred to local authorities in 2013/14, and it has fallen a further 13% in real terms since this transfer to 2019/20. National policy making remains too focused on how patient flow and treatment in acute settings can be improved rather than on preventative services in the community that help people avoid the need for acute care and how people can be best supported to regain the independence post discharge.

20. The pandemic has brought these issues into sharp focus, and SCC wants the government to work with the ASC sector and the public health profession to invest far more in prevention and community services which will lead to significant long term societal and financial benefits.

How should additional funds for the ASC sector be raised?

21. There are several options for funding the future ASC system including:

• National taxation, for instance through changing the current national insurance contributions model to one that ringfences a proportion of these contributions for people’s future care costs.
• Mandating people to take out private social care insurance to be drawn upon by individuals and the state when people require care.
• Local taxation through giving local authorities the flexibility to raise funding without nationally set constraints like those that have been imposed on the ASC precept.
• Diverting funding away from the NHS and other government departments, especially to enable greater investment in preventative community based social care and public health services that will deliver benefits to the NHS and other public services.

22. The decision about which of these, or any other, options to adopt is of course highly political and will in large part be driven by broader changes agreed to the state’s current national model for funding ASC services. We must determine at what levels and via what means people should contribute towards their care and if so whether this contribution should be capped in any way. This could lead to wider debate around what qualifies for free health care, with people possibly asking why personal life choices and risky behaviours are supported by care fully funded by the state while conditions like dementia and autism are not. These are questions that successive commissions such as the one chaired by Andrew Dilnot have grappled with, but in spite of many recommendations about how the social care system could be reformed, no government has been willing to implement the radical reforms needed.

23. SCC considers that whatever the national conclusion on these complicated and controversial issues, a mix of the funding options set out above is likely to be preferred. SCC would, however, like to caution that the private insurance model could lead to greater inequity, could be much harder to manage if people move around the country and / or regularly changed insurers, and could be more costly to operate as a result.

24. SCC would also like to highlight some key issues to take in account when government decides upon the level of funding required and the methods by which to raise funds:

• We must avoid tunnel vision in trying to design funding solutions that are focused on supporting the very small numbers of older people (in the context of the whole population of people who access ASC service) who face catastrophic care costs (i.e. all of their personal wealth is spent funding their care). This is a constant focus of politicians but is not the only major issue to solve in terms of ASC funding reform.
• A much greater focus must be placed on policy reform and funding changes for working age adults with disabilities, including learning disabilities, and mental health problems. This group can often have complex needs that require a lot of resource. When contributions people currently pay towards their care are taken into account, this is in fact the biggest area of ASC spending by local authorities, but national rhetoric about ASC policy reform is almost always focused on older people. Reform of the likes of housing benefit, universal credit and disability support payments is critical to meet the often massive demands and quality of life issues this group and their carers face.
• The methodology for distributing ASC funding to local authorities should be updated based on policy changes. For instance if a cap on care costs as suggested by the Dilnot Commission, were to be introduced then authorities such as Surrey, with a large number of people who currently fund their own care, would need to receive a much bigger share of any national funding allocations than is currently the case.

How can the ASC market be stabilised?

25. The additional funding provided by government through the Infection Control Fund (ICF), Rapid Testing Fund (RTF) and ASC Workforce Capacity Fund (WCF) has been vital in helping to stabilise the ASC sector. This funding has been deployed successfully in Surrey, and the confirmation of further ICF and RTF for first quarter of 2021/22 is also welcomed by SCC.

26. The level of concern among Surrey’s ASC provider sector has reduced considerably since the height of the pandemic. Providers will, however, continue to face increased costs due to infection control and some more traditional care services, particularly care homes and building-based day care, may fail due to reduced occupancy caused by the pandemic.

27. SCC will be urging the government to provide further additional funding beyond the third round of ICF funding for local authorities to invest themselves. In SCC’s case, with our local market knowledge and relationships with the provider community to support the continued recovery and transformation of the ASC provider sector, we would focus this investment in three main areas:

1. Investing in the expansion of services that support people to maximise their independence in the community, such as specialist extra care housing, independent living or community outreach services.
2. Working in partnership with providers who are willing and able to evolve their business models from traditional institutionalised models of care to those focused on supporting people to maximise their independence in the community. This could, for instance, involve converting residential care services to those designed to support independent living or transforming building-based day care into community outreach provision.
3. Providing further time limited additional financial support to ASC providers to ensure continued supply of sufficient capacity and quality of services while the ASC provider sector transitions to new ways of working. The aim is to provide targeted support based on local market intelligence. It would be important to ensure that all additional support provided is used to develop and deliver services that benefit residents.

28. For this funding model to work effectively, local authorities must have the flexibility to make decisions based on their local market knowledge and the extent to which models of care need to shift in the different local care sectors. As such, if government was to agree to provide further funding, SCC would expect it not to mandate how this funding should be spent, for instance dictating the amounts spent on care homes and CQC registered community services, as has been the case for ICF allocations. Whilst SCC also recognises the importance of local authorities reporting how funding has been deployed to government, the reporting regime should be less onerous than has been the case for the ASC Covid grants, with a longer timeframe for deployment of the funding to maximise how effectively it can be used.

29. In order for the government to form a clear view on the amount of sustainability funding required and the proposed uses of this funding across the country, local authorities could be asked to submit plans setting out how much funding they would wish to apply for within an agreed set of parameters. This must not though become a competitive bidding process, as this would risk local authorities not receiving the correct amount of financial support for their local area and would also risk creating unwelcome competition between authorities at a time when we should all be working collaboratively together.

How can the ASC market be incentivised to compete on quality and/or innovation?

30. To improve competition on quality and innovation the model of paying for care must shift from simply paying for inputs (e.g. the number of hours of care) to one that places greater onus and financial rewards on the delivery of agreed outcomes (e.g. enabling people to do things more independently which in turn would reduce the requirement of paid for care).

31. We do, however, recognise the difficulty of moving to an outcomes-based system and in structuring “payments by results” type contracts. At the present time this would represent a significant change from the current arrangement where ASC providers are paid the same amount until a formal review of a person’s needs is conducted by the local authority leads to a variation in the care package. Additionally, moving to a system that enables people to live more independent lives than at present could entail a contractual approach that is more complicated to operate and maintain. These problems are not insurmountable though, and SCC would welcome the opportunity to contribute to national policy development in this area, bringing together local authorities, ASC providers, the NHS and national government to develop proposals that would facilitate the implementation of outcomes-based commissioning across the country.

32. The other key area of innovation is TECS. Like most authorities, SCC is taking forwards its own programme to explore the potential and expand the offer of TECS in the county. This includes remote health monitoring in peoples' homes and smart technology to enable some replacement of person-based support hours so that the ASC workforce is able to focus on the more skilled work, and with the pace of the technological change new opportunities for service innovation are quickly becoming available. SCC will be urging government to fund more research into this rapidly expanding area and consider how more incentives can be offered to encourage organisations to develop TECS solutions. TECS tools will become increasingly important to support people to safely maintain their independence in the community and limit the cost of care provision.

Closing words

SCC looks forward to the recommendations of the Committee and we would be very happy to provide further information or assistance as needed. We hope this Inquiry will help inform the government’s thinking on the long-term funding reforms of adult social care that have been so urgently required for so long.

April 2021