Written evidence submitted by the British Medical Association [ASC 054]

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

The BMA is a member of the Health for Care, a coalition of health organisations that have joined forces to make the case for a sustainable social care system, backed up by a long-term funding settlement. The BMA have signed a letter from the coalition to the Housing, Communities and Local Government Committee’s inquiry into long term funding of adult social care, this submission should be seen alongside the letter from the coalition.

Summary

1.1   The BMA welcomes the opportunity to respond to the Housing, Communities and Local Government Committee’s inquiry into long term funding of adult social care. The social care system needed reform and increased funding before Covid-19, the situation has only been exacerbated by the Covid-19 pandemic.

1.2   The Covid-19 pandemic has meant that most non-Covid-19 NHS services were running at reduced capacity or shut down for significant parts of the last year, meaning that there is now a huge backlog of care. This will create further pressure on social care services as those in care wait for treatment from the NHS.

1.3   Social care needs a significant funding boost. The Health Foundation recently published analysis that the sector will need an extra £14.4bn over the next nine years to meet future demand, expand access to care and improve the care that is provided[1]. It is up to the government to determine which taxes this funding should be raised from. But it is important to recognise that public polling has shown public support for paying more taxes to maintain and improve health and social care. A Survation poll in 2019 showed that 73% of the population surveyed support a tax increase to pay for adult social care[2].

1.4   Part of the much-needed funding increase for social care must be used to support the existing workforce and expand it to fill the estimated 112,00 vacant roles at any one time in 2019/20[3]. Improving training and pay would no doubt improve the quality of care provided, as well as help increase recruitment and retention of social care staff.

1.5   Very few people have access to free social care in England, with free social care only available to people with low savings, assets, or the greatest needs. Increasing access to free care will improve the lives of those who need care and, importantly, reduce pressure on the NHS.

1.6   Any assessment of the state of social care should include care provided in peoples’ homes and care provided in care homes. Better integration of local NHS, social care and community services can help prevent people from needing to go into a care home, as well as preventing avoidable need for NHS care.

1.7   Greater focus on and investment in public health services is needed, particularly for middle and older age adults, to prevent or delay the need to access care services.

2. Impact of Covid-19

2.1   Prior to the pandemic the health and social care sector was already under significant pressure. Covid-19 has placed enormous additional strain on both services. Social care was particularly affected by the NHS England/Improvement decision communicated to trusts on 17 March 2020 to ‘expand critical care capacity to the maximum’[4], by urgently discharging all hospital in-patients who were thought to be medically fit. This included transferring hospital patients back into care homes without making it mandatory for them to be tested for Covid-19[5]. The impacts of this have been well documented.

2.2   From 14 March 2020 to 5 February 2021, there were 37,895 confirmed or suspected Covid-19 deaths amongst care home residents, almost 25% of all care home resident deaths in that period. There were 153,724 deaths from 14 March 2020 to 5 February 2021, 32,223 more than the average number of deaths in the years 2015-2019, an increase of 26%.[6] Covid-19 has also disproportionally impacted certain population groups in social care, with the proportion of deaths due to confirmed or suspected Covid-19 being higher for people from black and Asian backgrounds[7]. Social care staff – mostly women and more ethnically diverse than the general population – have been around twice as likely to die from Covid-19 than other adults[8],[9].

2.3   Although the government has provided additional funding for social care to cope with the impact of Covid-19, support for the sector, particularly regarding access to PPE and testing came too late. The House of Commons Public Accounts Committee concluded that ‘social care providers and staff were left exposed and vulnerable’ and found the Department of Health and Social Care (DHSC) provided NHS trusts with 1.9 billion items of PPE between March 2020 and July 2020, equivalent to 80% of estimated need, but only provided the adult social care sector with 331 million items, 10% of estimated need[10].

2.4   The Covid-19 pandemic has created a considerable and still growing backlog of care. The reduction and in many cases the shutdown of non-Covid-19 services during the first wave, cancellations of elective procedures during the second wave and changes in patient behaviour mean the NHS is now facing a huge backlog of care. The number of patients waiting to start treatment has risen to 4.7 million and the number of people waiting more than 52 weeks to start hospital treatment in February 2021 was 387,885 – the highest number for any calendar month since December 2007[11]. This significant backlog will create further pressure on social care services as those in care wait for treatment from the NHS.

2.5   In short, the sector has been overstretched, underfunded and understaffed for far too long. The pandemic has emphasised the need for well-funded, integrated services and the crucial role social care plays in the care of patients. It has also raised awareness of the important role played by those who work in social care, and the relatively poorer terms and conditions they tend to receive.

2.6   It is crucial that government learns the lessons from Covid-19 and implements long-term reform of social care services.

3. Increase in funding needed

3.1   Social care needs a significant long-term funding boost. Funding for social care across the UK has not kept up with rising demand for services. Demand for social care is rising with an ageing and growing population. The cost of social care in England is projected to rise by around £12 billion by 2030/31, growing at an average rate of 3.7% a year[12].

3.2   However, government expenditure on social care in England has fallen by 5% in real terms since 2010/11, meaning investment in service delivery and the social care workforce are at an all-time low[13]. This means total expenditure on social care in England is still £300 million below the level it was in 2010/11 in real terms, despite increasing demand for services[14].

3.3   This reduction in spending has taken place at a time when the cost of social care has increased. For example, between 2017/18 and 2018/19 the cost of residential care for a person over 65 increased by 5%[15].

3.4   Recent analysis from the Health Foundation estimates that to meet the expected growth in demand from an ageing population, improve services and pay for more care, an extra £14.4 billion is needed by 2030/31[16]. This does not yet account for the impact of Covid-19, which is unclear at present.

4. Workforce shortages and need for investment

4.1   In October 2020 Skills for Care estimated that 7.3% of roles in adult social care were vacant at any one time in 2019/20, equivalent to 112,00 vacancies[17]. It is estimated that 1,100 people leave their job in social care in England every day – an annual leaver rate of almost a third – and a quarter of staff are on a zero-hours contracts[18]. If demand for the social care workforce grows proportionally to the projected number of people aged 65 and over, then the number of social care jobs in England will need to increase by 36% to around 2.2 million jobs by 2035[19].

4.2   Social care falls under the category of a low paying sector – directly affected by government funding[20]. Most workers are paid at or around the national living wage and opportunities for progression and pay increases are very low. The pay difference between care workers with less than one year of experience and those with more than 20 years of experience has reduced to just £0.15 an hour[21]. This is a major influence on retention of the workforce.

4.3   Typically, the NHS provides better working conditions compared to those currently provided in the social care sector in terms of pay, career progression and terms and conditions. For example, health care assistant roles in the NHS can be extremely attractive to staff in social care and there is a 7% gap between pay for nurses in adult social care and in the NHS in England.

4.4   In short, there are clear workforce shortages within social care, and to address them pay for social care workers must be increased. It has been estimated that £3.9bn[22] will be needed in 2023/24 to meet increased demand and increase pay for social care staff.

4.5   However, extra investment is also needed to improve training and professional development. Like healthcare professionals, social care workers should have the opportunity to be recognised for the skills and knowledge that can be gained after a few years’ experience working in the sector with possible pathways to specialisms in health conditions such as dementia, learning disabilities or palliative care. It is crucial that there is investment in training and continuing professional development of social care staff as a step to professionalising the workforce.

4.6   The health and wellbeing of social care staff also needs to be prioritised – particularly in the wake of the pandemic. Improving retention of staff and reducing turnover play an important role in improving and maintaining health and wellbeing of the existing workforce. Staff will stay if they feel valued and better supported to do their jobs. Measures implemented to support the longer-term mental health and wellbeing of staff in the NHS also need to apply to social care[23].

4.7   All of this would improve the quality of care provided, retention and make joining the sector more attractive.

5. How should funding be raised?

5.1   Funding for social care should come from general taxation. It is up to government to decide which taxes this funding should be raised from.

5.2   There does appear to be support from the general population for paying more taxes to maintain and improve social care. A Survation poll in 2019 showed that 73% of the population surveyed support a tax increase to pay for adult social care[24]. Additionally, a recent Health Foundation study found that 62% of respondents said that if the government decided to increase spending on social care, this should be funded through some form of tax increase, up from 51% in May 2018[25].

6. More access to free care is needed

6.1   Only limited numbers of people have access to free social care. In 2019/2020 only 17% of requests for care from working age adults were granted and 30% of requests for care from older adults[26].

6.2   Social care is only provided free to people with low assets and savings. For example, in England everyone with assets of more than £23,250 must pay for themselves, rely on family, or go without. Therefore, some people with significant care and support needs (the Dalton Commission estimated 10% of those over 65 years old) will end up paying very large sums – £100,000 and above. Since 1999, an estimated 330,000 people in the UK have had to sell their homes to pay for social care[27].

6.3   Some people are also excluded from public support because their condition (or ‘need’) is not considered serious enough for them to be entitled to publicly funded support. It is estimated that 1.4 million older people in England fall into this category and are not getting the care and support they need[28].

6.4   Support for ‘lower-level’ need may help prevent people’s conditions deteriorating, avoid putting unrealistic expectations on family carers and reduce the risk of individuals needing more costly and resource intensive health and social care services in the future[29]. It has been argued that personal care (in home help with daily tasks such as bathing and dressing) may reduce the overall per-head cost of social care by ensuring that more people access care at home rather than a more expensive care home[30].

6.5   It is important to reduce the risk of people needing to access hospital services or long-term residential care. Despite the large residential care population, most older people would prefer to stay at home with polls confirming that more than nine in every 10 people (97%) do not want to move into residential care[31].

6.6   More social care services, such as personal care, should be free to increase the availability of and access to care. This will improve the lives of those who need care and help reduce pressure on the NHS by reducing delays in finding care packages for vulnerable patients.

7. Further integration of care

7.1   Integration of local NHS, social care and community services can contribute to holistic preventative care. It has been estimated that a quarter of all emergency admissions from care home residents may have been potentially avoidable with better provision of preventative primary care, community support or NHS care in care homes[32].

7.2   Better integration of care homes and community teams could provide benefits for residents and reduce pressure on the NHS. For example, community nurses visiting care homes can provide in-house medical treatment for minor issues, preventing the need for more costly NHS care or emergency admissions in the longer-term. Joined up services help to identify individuals most at risk and enable them to be treated in the community rather than in hospital settings, supported of course by adequate funding in the community.

7.3   To help with the integration of services, more consideration should be given to jointly commissioning and funding health and social care, so that professionals can work together more effectively, and resources can be used more efficiently[33]. Joint training of the health and social care workforce will also help to provide common skill sets and cultures, helping service users experience more joined up care.

7.4   Attempts of joint funding and commissioning of services have been made, such as the New Care Model Vanguards and the Better Care Fund. These have helped to improve joint working between health and social care, reduced emergency admissions and included community models that helped to keep people independent for longer[34]. But these models have also been dependent on additional investment to achieve this. It is crucial that schemes such as these are properly resourced, and any lessons learned are taken forward.

8. Public health investment

8.1   Public health services can play a key role in maintaining an individual’s independence and reducing the need to access social care and long-term health care. For example, an individual’s need for social care is often based on their level of activity and function and becoming frail can be prevented or reversed with exercise and activity programmes[35].

8.2   Greater focus on and investment in public health services is needed, particularly for middle and older age adults, to prevent or delay the need to access care services. Since 2015, the public health grant was subject to severe funding cuts, which by 2020/21 are estimated to amount to a £1 billion real terms funding cut relative to 2015/16 levels. The government must restore these cuts in full to enable local authorities to deliver vital preventative services that protect and improve health[36].

April 2021