Written evidence submitted by the Association of Directors of Adult Social Services (ADASS) [ASC 070]

Introduction

The Association of Directors of Adult Social Services (ADASS) welcomes the opportunity to submit evidence to the Housing, Communities and Local Government Committee Inquiry into the Long-Term Funding of Adult Social Care.

Adult social care provides care, support, and safeguards for those people in our communities who have the highest level of need and for their carers.

Adult social care in England is estimated to contribute £40.5 billion annually to the economy.[1] There are a total of 1.62 million jobs and 1.52 million people working in social care in England with annual projections of jobs rising. The indirect effect of the sector is estimated to contribute a further 603,500 jobs across the UK. Yet the political debate remains one of managing the costs. We need to change this and talk about the sector more positively.

Context

Prior to the pandemic, adult social care already faced significant and ongoing challenges. These included, but are not limited to, the following:

The use of short-term and time-limited funding settlements to support adult social care budgets, including the Improved Better Care Fund (iBCF);
Increasing demographic pressures and more people living with complex needs;
Increasing levels of unmet and under met need;
Insufficient resources to invest in early intervention and prevention in a meaningful way;
Shorter hospital lengths of stay (including for people with learning disabilities and mental ill health) and reductions in community, mental health and primary support as a proportion of NHS spend and thus increasing complexity of health and care needs in the community;
Issues relating to EU Exit, including significant related workforce issues;
Recruitment and retention of the workforce; and
Fragile care markets;

During the first half of the last decade Directors of Adult Social Services (DASSs) managed significantly reduced budgets by managing down the cost, quality and quantity balance - squeezing prices paid for care, tightening eligibility (and thus the numbers of people receiving care) and letting contracts where there were economies of scale. In relation to the latter, this resulted in the commissioning of very large nursing homes for older people, arguably a model counter to the direction for younger people, where the move was to more personalised, small scale services in the community. Care Quality Commission (CQC) data shows that the quality in those larger establishments was lower. ADASS questioned the sustainability of the approach as efficiency measures increasingly became counter-efficient, particularly in the context of the welcome but not fully funded impact of the National Minimum and Living Wage policies. For example, in the year that the NMW and NLWs went live (2016), our Budget Survey report highlighted the deficit between the amount raised by the Adult Social Care Precept (£380m) and both the direct council costs and increased provider fee costs (£520m,plus at least £92m in further costs associated to the National Minimum Wage).[2] This gap has existed for every year since the policy was introduced and has been reported in every ADASS Budget Survey since 2016.

In recent years a growing number of cross-party parliamentary committees have highlighted the need for Government to deliver a long-term strategy and sustainable funding settlement for adult social care. In particular, the House of Lords Economic Affairs Committee made wide-ranging recommendations that address many of the issues, including those relating to workforce, unpaid carers and unmet need, highlighted above.[3] The Health and Social Care Committee inquiry into funding and workforce recommended that the ‘starting point for the social care funding increase must be an additional £7bn per year by 2023–24 to cover demographic changes, uplift staff pay in line with the National Minimum Wage and to protect people who face catastrophic social care costs’.[4] The Public Accounts Committee has also highlighted significant concerns on a number of occasions that Government was ‘not delivering on its overarching responsibilities towards the care market, and having no credible plans to ensure the sector was sustainably funded’.[5] Significant evidence and cross-party support for reform and the provision of a sustainable funding settlement for adult social care is well-documented. However, to-date this has yet to prompt the publication of Government proposals to the detriment of us who access care and support and work in the sector.

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

Covid-19 has highlighted and increased the disadvantages and inequities experienced by women, working age disabled people, those of us with learning disabilities and/or autism, Black, Asian and Minority Ethnic communities and older people. As we reset and rebuild social care, including long-term funding reform, it is vital that we proactively tackle historic inequalities and injustices, whilst ensuring that the new models of care that are nurtured and developed as a result of the reforms are equally relevant, accessible and vital to all groups. We must ensure equality of access and outcomes for all.

The onset of Covid-19 has also only served to magnify the challenges set out in the previous section, including around fragile care markets and workforce, and bring them into view of society more broadly.

It has amplified the social supports that are needed in relation to rough sleepers with mental ill health and/or addictions, people fleeing domestic abuse, people who are vulnerable and shielding and carers – including those giving up work. During the first wave of the pandemic there was an early release of prisoners with care needs. Nobody noticed. What does that say?

The pandemic has changed the patterns of people approaching councils for help. It will have consequences that are only emerging in relation to Long Covid, the impact of poverty, safeguarding and domestic abuse and safeguarding and quality in care provision that has been behind closed doors. The pandemic has also had some positive impacts. It has highlighted the necessity of the social care workforce for the public and the inability to provide care in congregate settings (whether day centres or care homes due to increased anxieties related to group/communal support) has led to the development of more personalised home-based options.

It has also made it abundantly clear that adult social care cannot continue to limp from year to year, relying on short-term or time limited funding settlements.

The additional impact of Covid-19 on local authority expenditure and income has significantly affected the proportion of Directors stating that they are fully confident that they will be able to fully meet their statutory duties for adult social care. In 2020/21 only 4% of DASSs stated that they were fully confident, this compares to 35% in 2019/20.[6] This means Directors doubt their ability to provide the full range of information and advice, support wellbeing and prevention, provide assessments and direct payments or the arrangement of care and support, maintain care markets and safeguard people with care and support needs from abuse and neglect, or at risk of being deprived of their liberty.

This is why we called for the Chancellor to put meeting the needs of older and disabled people, carers and families at the heart of his plans for economic recovery by:

Committing to longer-term funding through a 10-year plan for adult social care, starting with recovery from the crisis and moving on to major investment in preventive community services. This must include early agreement on a comprehensive workforce strategy which sets a social care minimum wage of £10.90 an hour.

Reform that transforms social care into a pillar of a 21-century welfare state, delivering quality support for people of all ages that enables us to live the lives we want in the place we call home and in communities that look out for each other.

We need a social care-led recovery from Covid-19. Social care must be seen as an opportunity and not a political issue that’s kicked back into the long grass. It must be seen as an investment in the infrastructure of the country and a means of getting it back working. For example, in the United States, of President Biden's £2 trillion infrastructure fund, £400 billion is for care at home and much of that for improved pay and conditions for care workers.

If Government commit to significant and sustainable investment in the sector, as set out above, it offers an opportunity to support people into employment at a time when unemployment is running at 5.1% in England.[7] Pre Covid-19. the sector has high vacancy rates of 122,000 FTE, with 77,000 of these vacancies being for care worker jobs.[8] If these jobs were filled it would help reduce the number of people accessing universal credit, increase tax receipts and most importantly enhance the support available to those of us with care needs.

In many ways the economic potential of adult social care has not been utilised to its full extent. The sector already contributes £40.5billion in GVA annually. There are also wider economic benefits of adult social care. Through investment in prevention, early intervention and wellbeing and by supporting people to remain independent, adult social care reduces the need for more costly interventions. Social care also supports people receiving care to remain, or become, economically active through supportive care planning. Direct payments mean many people with care needs are themselves employers. Therefore, social care must be one of the building blocks to start rebuilding the economy as society begins to reopen.

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

Our collective starting point must be a conversation about the types of care and support we want for ourselves and our families, today and in the future and how we pay for it. Our goal must be to engage and involve those of us with care and support needs, our families and carers, those who work in social care and all other key stakeholders in defining the task before us and in ultimately establishing the framework for the way that care will be delivered and experienced in the future.

This should meaningfully explore the broad range of possible models of care available as well as enabling an honest conversation about what we can afford and ultimately how we pay for the care we want and need and share risks across individuals and the state. This process must settle the national question of how to pay for, and whether to charge for care, and how to align arrangements with health and housing.

Funding should cover the range of needs, be fair and based on the best balance of taxation, potential re-prioritisation of other benefits (pensions and non-means tested benefits), an individual’s contribution and private insurance. There should be fairness between and within generations (noting that the nature of home ownership is continuing to change and such capital sums as are currently available to some of the older generation may not be in years to come). Government in developing reforms should also recognise that the areas of England have different geographies, rurality, demographic and socio-economic influences. Funding solutions should be long-term and capable of being adjusted at periodic intervals.

Whatever the mechanism chosen and however much the state is prepared to pay for care, we expect the system to be simple and easy to understand and administer.

How can the adult social care market be stabilised?

We, along with others in the sector, have provided significant evidence to Government for several years of the ongoing and intensifying unsustainability of care markets. The onset of Covid-19 has only served to heighten the risks of market failure for a growing number of providers.

The pandemic has made extremely fragile care markets even more susceptible to market failure, to the detriment to those people accessing care and support services. Before the pandemic 1% of Directors of Adult Social Services were concerned about the sustainability of ‘most’ or ‘all’ residential and nursing care providers. This has now risen to 32% of DASSs. More than half (53%) of DASSs have received requests for financial support from care homes, which have seen significant reductions in self-funding residents.[9]

The provision of short-term Government grants since March 2020 has enabled providers, to a significant extent, to remain viable. However, we are concerned that the point at which the provision of these grants ceases, or a longer-term funding settlement for adult social care is not delivered, that there will be a significant impact on the viability of the market.

The costs of delivering care and support are increasing while Directors have indicated that the numbers of viable providers are decreasing This is clearly unsustainable and is detrimental to local authorities being able to deliver on their Care Act duties to shape and commission a vibrant, diverse, sustainable and high-quality markets. Most importantly it hinders the quality and choice of provision of those of us with care and support needs.

It is important to recognise when reading the figures below that every closure, or contract hand back, has a direct impact upon the health and wellbeing of that individual and also their families. Unplanned care home closures are also known to impact on mortality.

The ADASS Autumn Survey, published in November 2020, found that 60% of DASSs reported that providers in their area had closed, ceased trading or handed back local authority contracts between April-September 2020, impacting 3,309 people in total.[10] This compares to 43% reported in the 6 months prior to the ADASS Budget Survey (October 2019-March 2020). The remaining 40% had not experienced any provider closures, cessation of trade or contract hand backs over the same time period. We are currently in the process of gathering data on care market sustainability over the past 6 months and this is likely to be published in May 2021.

It is important that as we consider the longer-term future of our care markets that we do not do anything that risks limiting our options for change. Therefore, any short-term support (particularly in the immediate post-Covid-19 period) for particular types of care provision should be tied to a commitment to participate in the reform conversation and where necessary to downsizing particular types of provision, such as potentially some forms of care home provision. This will enable us to better match demand and capacity in the short-term and avoid tying us into forms of care that people do not ultimately want for themselves or their families.

Looking forward, it is vital that market reform seeks to shift the reliance on institutional to community-based models of care. This must be underpinned by the ‘Home First’ principle. This is likely to mean a much stronger emphasis on some existing types of care and support which are housing based, such as ‘supported living’ and ‘extra care housing’, as well as new and innovative forms of care and support.

This in turn may mean a shift away from existing types of residential care, for example, a lesser reliance on long stay, larger scale care homes although they may continue to play a key role in reablement and short-term care. Today’s models of care have developed as a result of local authorities being left with little choice, as a result of challenging funding settlements from Government, but to relentlessly drive down price to deliver legally required balanced budgets, rather than focus on delivering what people want. Very large nursing homes for older people are a result of years of austerity. They would be completely unacceptable for people with learning disabilities or other working age adults. There is an inverse relationship between size and quality and size and the impact of Covid-19.

It is worth also looking at the prison population and the number of people with mental ill health, substance misuse, learning disabilities and autism who have ended in the criminal justice system and the cost implications of that vis a vis support in the community in relation to care not custody.

To achieve this aim, we are advocating for a significant national expansion in extra care housing, sheltered housing and floating support through dedicated funding, with local authorities given an expectation of a significant multi-year programme. We should review current housing rights for people in care settings to strengthen the right to live at home, to remain at home following a change of care needs, and to be discharged home after a spell in hospital.

Care markets should not be debated in isolation. Those of us who provide unpaid care are fundamental to the ongoing sustainability of adult social care. During the pandemic, the number of us who provided unpaid care rose dramatically at one point as many as 13.6 million carers across the UK or one in four of the population. This includes 5 million additional people who have taken on caring responsibilities during the pandemic. Research from Carers UK found that the value of their support outside of the pandemic is £132 billion to the national economy (an average of £19,336 per carer), roughly equivalent to the value of the NHS. During the pandemic, the value of their support has been £530 million per day (£435 million in England).[11]

As part of Government reform proposals, ADASS has recommended that an Adult Social Care Workforce Strategy should be developed and look at the support available to enable those of us that are family carers to combine our caring responsibilities with our own careers. Making clear what support is available from both the state and from our employers. Over the next two decades, social care will only be sustainable if we prioritise and enable those of us that provide unpaid care to take on and maintain our caring responsibilities. In return, as a society we must recognise, support and reward them.

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

Stability of funding, as highlighted above, will be a key facet if the adult social care market is to be incentivised to compete on quality and/or innovation. Maximising the use of the funding currently in the system, along with a long-term plan and funding settlement for adult social care will provide much needed certainty and confidence for local authorities and providers to invest and evolve the market.

A key factor in the quality of services is the continuity of the workforce. Skills for Care also found a link between levels of turnover and quality. Establishments with overall ratings of inadequate or requires improvement had higher turnover rates compared to those that had good or outstanding ratings (32.2% and 29.5% respectively).[12]

This is why the National Institute for Health and Care Excellence (NICE) include Continuity of Care and Support as part of their Quality Statement for People’s experience using adult social care services.[13] This is why there is general consensus that high vacancy and turnover rates make it more difficult to achieve and maintain good standards of care.[14]

The value of continuity of care is further supported by the International Longevity Centre (ILC) who stated:

‘One of the reasons that continuity of care is so important is that it leads to better coordinated care – employees across the care sector have to work effectively together as well as with those in the health service. Greater continuity of staffing enables better relationships both within and across sectors to ensure that any health issues are quickly identified and well managed.[15]’

Continuity not only delivers savings to providers in terms of reduced recruitment and training costs, more importantly it also has wider benefits for the health and social care system more broadly and a critical impact on the quality and safety of the care of an individual.

About Us

The Association of Directors of Adult Social Services is a charity. Our objectives include:

Furthering comprehensive, equitable, social policies and plans which reflect and shape the economic and social environment of the time
Furthering the interests of those who need social care services regardless of their backgrounds and status and
Promoting high standards of social care services

Our members are current and former directors of adult care or social services and their senior staff, including Principal Social Workers.

April 2021

[8] Skills for Care: The state of the social care sector and workforce in England (Sept 2019)