Written evidence submitted by Age UK [ASC 055]

Age UK is the country's largest charity dedicated to helping everyone make the most of later life. The Age UK network comprises of around 150 local Age UKs reaching most of England. Each year we provide Information and Advice to around 5 million people through web based and written materials and individual enquiries by telephone, letters, emails and face to face sessions. We work closely with Age Cymru, Age NI and Age Scotland. Local Age UKs are active in supporting and advising older people and their families in the care market.

1. A social care system in crisis

The challenges faced by the social care sector are deep rooted and systemic. The system has been staggering along for years, in financial crisis and unable to deliver the increasingly complex levels of care many older people need. There is no doubt local authorities have been unable to keep pace with cost pressures in the sector, and that the demand for care has progressively outstripped what their diminishing funding has been able to supply.

While a number of short-term cash injections from government have helped ease these pressures to a degree, local authority net spending on adult social care was lower in 2019/20 than in 2010/11, representing a real terms reduction of 4% in local authority spending, while government funding for local authorities – who arrange most formal care – fell by 55% in 2019/20 compared with 2010/11, resulting in a 29% real-terms reduction in local government spending power[1].

As scope for year-on-year efficiency savings has reduced, and funding remains inadequate, there is clear evidence local authorities have managed social care funding pressures by other means, including service reductions and smaller care packages, as well as stricter eligibility criteria, and suppressing the prices paid to providers[2]. For example, in the last year, there were 1.35 million new requests for social care support from older people, however just over half (51%), resulted in either no services being received or the older person being signposted to universal services or elsewhere[3].

Further, the number of older people receiving local authority long-term care over the course of the year has decreased year-on-year – from 599,680 in 2014/15 to 548,435 in 2018/19. This is an 8.5 per cent reduction over the five-year period. There has been a 7.3 per cent reduction in the number of older people receiving residential or nursing care between 2015/16 and 2018/19, and a 10.1 per cent reduction in the number of people receiving community support over the same period[4]. This is despite rapid growth in the size of the older population over the same period, particularly amongst those over the age of 85 who are most likely to live with high levels of need.

Reductions in state funding on this scale has also had a considerable impact on those individuals who fall outside state funded provision. Known as self-funders, these individuals have been left to pick up the increasing costs faced by providers and, as a result, it is estimated a self-funder now pays an average of 41% more for the same package of care as that arranged and paid for by the local authority[5]. These costs add up, and in total can be catastrophic. It has become common place for older people to sell their home or spend a lifetime’s worth of savings to pay for a care bill they could not plan for. It is probably fair to say that this cross subsidy is a key factor in why the social care system has not entirely collapsed to date. Unfortunately, we know very little about what happens to self-funders in the domiciliary care market due to a paucity of data. Indeed, we cannot even be certain how many people access domiciliary services. However, the evidence in so far as it exists suggests these issues are not unique to residential care.

These seismic funding issues have led to significant market instability and insufficient capacity in the system. This has particularly been the case for nursing care, where in some parts of the country the number of nursing home beds have fallen by more than a third in the last five years[6]. This has been coupled with significant levels of churn amongst home care owners and operators. There have also been major challenges in workforce capacity, where at any one time there are approximately 122,000 vacancies – nearly one in every 10 roles in the adult social care sector[7]. It is estimated that to meet the needs of an ageing society, the workforce will need to grow by 2.6% every year until 2035, to a total of 2 million jobs in care[8]. Domiciliary care, where the majority of people receive social care support, suffers from the highest vacancy and turnover rates of any role in care at 10.6% and 38.8% respectively[9]. 

Ultimately, the sustained underfunding, market instability and high vacancy rates endemic in the social care sector have taken a substantial toll on the physical and mental health of older people who have been catastrophically let down for many years. We have witnessed levels of unmet need rising steeply for all older people, irrespective of their access to formal or informal care or their ability to fund care. We now estimate that 1.5 million people over the age of 65 – nearly one in seven – are struggling without all the help they need to carry out activities of daily living (ADL) – essential everyday tasks, such as getting out of bed, going to the toilet or getting dressed[10]. We are particularly concerned with the estimate that 53 per cent of people aged 65 and over who are unable to complete three or more ADLs receive no help or help that does not meet their needs[11].

While the social care system buckles under the strain, loved ones of people with social care needs are increasingly expected to take on more caring responsibility themselves, often to a wholly unreasonable degree, and at the expense of their own health and financial security. The majority of care has always been provided on an unpaid basis by families and friends, however in recent years the numbers of people providing a form of unpaid care have risen rapidly[12]. Many of these carers are older people themselves, with an estimated 2 million carers over the age of 65, of whom 417,000 are aged 80 and over[13] and around two thirds of carers over the age of 60 living with long-term health problems or a disability[14].

The Government have made bold promises to ‘fix social care’. It is now time to deliver on these and deliver on a comprehensive funding solution for the social care system that recognises it as the essential public service it is. We owe today’s generation of older people and all future generations to come the guarantee that when need it, you will be supported to live an independent and fulfilling later life.

1. The current social care climate

The coronavirus pandemic has laid bare the deep and systemic inadequacies of the current social care system and revealed the true extent of the impact underfunding, structural issues and market instability have had on the system’s ability to respond and protect older people at a time of crisis. The chinks in the chain, which many were already acutely aware of, have been dealt their final blow, with catastrophic consequences for millions of older people, families and carers.

Even before the pandemic struck, the annual Budget Survey of Directors of Adult Social Services in England found less than 5 per cent of directors were fully confident of their ability to meet all statutory duties in 2020/21 and 2021/22[15]. The financial pressures on the social care sector have only been exacerbated. Rising prices to source PPE, loss of client income and agency costs for staffing have all played a part in this. Some reports have suggested that PPE costs have increased twelve-fold since the start of the pandemic[16]. Despite funding to the tune of over £1bn being made available to local authorities to help them support the social care sector to respond to COVID19 pressures, reports indicate the extent to which this funding has made it to the front line is hugely varied – especially at the beginning of the pandemic. Some areas have clearly used additional funding to work collaboratively in local health and care systems, addressing challenges in care homes. While in others this is not the case, with providers being told that it would be business as usual during the pandemic. Combined with sudden loss of income from empty beds in many homes, this has left many care providers at imminent risk of collapse. It is important to remember that around two thirds of beds in the market are provider by SMEs.

It has also brutally exposed the immense challenges the social care system has faced in protecting the health and meeting the needs of older people, who were widely understood to be amongst the most vulnerable to the effects of this virus from the very outset. Beset by a lack of any PPE, little to no testing of residents or staff, inadequate (or in hindsight misguided) guidance and policies, and limited access to clinical support, the sector also faced insurmountable levels of staff sickness – further depleting a workforce carrying large numbers of vacancies. Reports suggest that by the end of march an average of 25% of frontline social care staff were unable to work[17] and the sector experienced a 170% increase in the numbers of days providers lost staff to sickness. This equates to 2.3 million extra days lots to sickness in March and April than is usually expected[18].

To maintain safe staffing levels, care providers had to rely heavily on agency staff to fill gaps. With limited access to testing for care staff – who were considered a priority for testing much later than colleagues in the NHS – social care providers were unable to guarantee staff were COVID negative, relying only on visible symptoms as an indicator as requirement for self-isolating. Alongside poor access to PPE – another situation where the NHS was considered a higher priority - it was an impossible task for many care homes to truly limit the spread of infection. Not least because nearly all residents require personal care, with limited ability to socially distance.

The result of this has been a tragic loss of life. To date, there have now been 30,218 deaths of care home residents attributable to COVID-19[19]. It was during the first wave of the pandemic that just over half of these deaths occurred[20]. Between the 10th April and 8th May, the sector also saw 593 deaths of recipients of domiciliary care attributable to COVID-19, although it is possible this figure could be higher given domiciliary care recipients have been much less likely to have their death attributed to COVID19 than care home residents[21].

It is also now clear there has been a significant increase in loss of life more broadly for those receiving social care throughout the course of the pandemic. In fact, between 7th March and 22nd May, the number of people who died in care homes was more than double (110%) the usual number of deaths in care homes[22] and between 10th April and 8th May there were 3,161 deaths of domiciliary care recipients, 170% (1,990) more than the average for the same period in the previous 3 years[23]. While a proportion of these are no doubt attributable to undiagnosed cases of COVID19, particularly at early stages of the pandemic when atypical symptoms amongst frailer older people were less well understood, there have also persistent reports of deeply concerning ‘blanket’ policies being applied to older people living in care homes. These have included DNACPR orders for care home residents as well as policies around hospital transfer and admission of individuals. While we have welcomed clear statements from Government and NHS England that blanket policies are completely unacceptable, we are aware that practices have persisted locally. Anecdotally these appear to be contributing factors alongside on-going difficulty in accessing routine and urgent health care on behalf of residents.

The moral case for Government, on behalf of us all, to act on the systemic deficits of the social care system been laid bare by this pandemic is stronger than ever. Older people in receipt of care, in care homes especially, have been catastrophically let down and many have died before their time as a result. The fact that similar tragedies have unfolded in other countries too is no consolation and no excuse. Indeed, we must be quick to take up the lessons from those countries which have successfully safeguarded their most vulnerable citizens.  

2. The case for funding reform – meeting older people’s needs

Establishing a sustainable system for the future cannot mean more of the same. The government must support the sector to recover from the effects of the pandemic, equip it to protect the health and wellbeing of older people in the longer term and establish a new and higher standard for what older people and their families can expect from their care.

A model of social care, capable of meetings the needs of a growing older population and able to take its rightful place alongside the National Health Service as a core public service is vital. It must address serious challenges that have faced the sector for many years and work in partnership with individuals, their families, and carers to effectively meet people’s needs.

While funding alone is not enough, a comprehensive package of funding reform is the cornerstone of a new and improved system. As a starting point Age UK expects to see a long term solution based around the widely shared principles of social care provision free at the point of need, accessible to all and able to meet sufficient levels of need, such that all older people can be guaranteed support to live a dignified and fulfilled later life. 

The foundations of a new system must also be built on fully funded and comprehensive workforce strategy for adult social care, a vital step in ensuring any future system can adequately meet the needs of older people. As an essential part of this reform, social care should be an attractive and properly paid career, seen in parity with NHS counterparts.

This is particularly crucial, as it is currently the case that the NHS and social care compete for the same group of people, such as care assistants, nurses, occupational therapists and support staff, as well as people aspiring to those roles, but terms and conditions for social care staff are typically worse. While NHS staff have been awarded a real-terms pay increase up until 2020/2021, over half a million care workers are paid below the real living wage, the median pay for a care worker is £8.10 an hour and average salaries are around the £15,000. Moreover, around a quarter of these workers are on zero-hours contracts, including more than 50 per cent of the domiciliary care workforce[24].

Professionalising and upskilling the social care workforce is central to any workforce strategy and arguably the most pressing issue. People now live longer than ever before with much more complex health and care needs, a trend we expect to continue to accelerate over the next 20 years[25]. Yet a combination of limited training, no professional regulation and poor retention has meant that the social care workforce has been unable keep up with the progression of older people’s needs. Nor have the service and funding models that they work within. As a result, as the levels of acuity amongst social care service users has risen, services models have been left ill-equipped to meet this changing level of need, compounded by a historic lack of integrated delivery between the NHS and care services.

This has been evident across the sector, where provision for specialised domiciliary care is particularly limited and many parts of the country have experienced huge losses in nursing home beds – often because retention of nurses has been so difficult[26]. For many years care homes have reported finding it difficult to access good and regular GP support for care home residents, while falls – a preventable issue – remained the largest cause of hospital admissions for older people pre-pandemic. Despite the best efforts of dedicated staff, the pandemic has brutally exposed these weaknesses.

Often – although not exclusively – older people reach a point in their life where social care is required because their health has deteriorated, or they have become frail. However, it is sadly the case that many older people spend the last years of their life in a constant cycle between the place they live and hospital – waiting too long to be discharged from hospital while health and care professionals desperately try to arrange about adequate care packages. In 2018/19 there was an average of 4,564 delayed transfers of care per day in England[27].

Age UK is clear that the future of social care for older people must look at how provision can be put in place to deliver effective health and social care to an older person to support them to carry on living independently at home, or lead a fulfilling life in a residential care setting. It must be able to follow any progression of need and deterioration of health, particular as people come towards the end of their life, in a way the current system does not.

We recognise that the models of social care required, and degree of integration with health services, may be of a different order to those that best meet the needs of other groups whose need for care and support is not primarily driven by acute health conditions or end of life care. Any new funding package for the social care system requires a degree of flexibility to allow the system to integrated purposefully and in a way that makes sense to the person whose social care needs need to be met. While the solutions for how best to meet the needs of the wide array of people who need social care may need to be different, there is no compromise to be had on the fact that reform and refinance of social care must deliver for all.

Finally, a comprehensive funding package for the social care system must deliver a new deal for informal carers. The majority of social care is delivered by informal carers, yet their contribution often goes unnoticed, taken for granted by the social care sector and the state. The levels of support informal carers provide can be intense, with 34% of carers aged 80 and above providing 35 or more hours of care a week[28]. This comes at great cost to their own physical and mental health, especially given around 65% of older carers themselves live with long term health conditions. Carers often deprioritise their own health needs to ensure they can continue to deliver care to a loved one[29].

Yet the current system just keeps asking for more. Something that has only been exacerbated during the course of the coronavirus pandemic where limited community resources, such as day centres and respite services, that would have provided some relief for a carer have all but disappeared. Many individuals and families have also temporarily stopped domiciliary care packages due to the risk of infection. Around 70% of unpaid carers reported providing more care due to the pandemic and 55% felt overwhelmed and worried about burning out in the near future[30].

Informal carers will always play an important part in any social care system, but any expectation that informal care can continue to expand indefinitely, or that families can make up for a failing care system is unrealistic. A new deal for informal carers should provide the services and support needed to help deliver care, while recognising the personal financial implications of doing so with more generous financial support.

It is clear that the current system is not capable long term of delivering the right solutions for older people, their carers, the NHS or the sector itself. If this pandemic has taught us anything, it’s that a highly fragmented, underfunded system reliant on the enormous efforts of informal carers and piecemeal local arrangements, operating on the two separate tiers of state and self-funding clients is no way to deliver what is in reality an essential public service on which hundreds of thousands of older people depend. The State’s responsibility must be made clear and this and future governments must accept it.

April 2021