Written evidence submitted by MIN (SCF0028)

We're Mind, the mental health charity for England and Wales. We provide advice and support to empower anyone experiencing a mental health problem. We campaign to improve services, raise awareness and promote understanding.

Summary of response

1. Social care is the vital care and support that helps many people with mental health problems to live with independence, dignity and opportunity. When people aren’t able to get the support they need from social care, their mental health can get worse. This has a huge cost – both in terms of damage caused to the lives of individuals and the significant financial costs to society.
2. We call on the UK Government to publish their long awaited plan for social care and to set out long-term, sustainable solutions for the funding and provision. This must address the needs of working age adults, including those of us with mental health problems.
3. The UK Government should ensure that any long term funding solution for social care ensures there is better integration between health and social care services. For too long, the ability of people with mental health problems to get the social care they need has been undermined by a fragmented health and social care system.
4. We urge the UK Government to ensure that the social care system is equipped to meet the challenges arising because of coronavirus and find ways to support local authorities to deliver on their full duties under the Care Act.

Question 1

What impact is the current social care funding situation having on the NHS and on people who need social care?

Impact on people with mental health problems who need social care

5. Total public spending on mental health support, under adult social care for adults aged 18-64, added up to £830 million in 2016/17.  This represents 8.7% of the total spend on social care for working age adults (£9.5bn)[1]. Public spending on social care fell significantly from 2009/10 – whilst funding has increased since 2014/15, the total funding remains below previous levels. Three quarters of cuts were achieved by reducing the amount of care provided and the rest by paying less.[2]
6. A consequence of the underfunding of social care for working age adults is that people with mental health problems struggle to get the care they need.
7. Reforms to local government finance present a risk to local authorities’ ability to fund social care - revenue from council tax and business rates is unlikely to keep pace with the rising costs of adult social care services.[3] Many local authorities won’t be able to raise more revenue via the social care precept. In any case, the amount raised does not correlate between the local variation in the amount raised and need for care.[4]
8. The pressures of underfunding are culminating in fragile care markets; provider failure; workforce shortages; deteriorating quality and an unsustainable reliance on people self-funding in care homes.
9. This is in the context of rising care costs[5] and increasing demand – an ageing population and longer life expectancy of those with physical/mental health needs. Half of current demographic cost pressures arise from needs of working age adults.[6]
10. People’s mental health can get worse if they’re unable to get the social care support they need, leading to financial costs for the NHS. For example, an evaluation of ‘The Hub’, a service run by Mind in Croydon which aims to meet some of people’s social care needs, found that the service saved £418,509 due to a reduction in hospital admissions. In the year prior to The Hub, there had been 42 hospital admissions and at one year follow up, this had reduced to 3.[7]

Experiences of social care for people with mental health problems

11. When Lee was diagnosed with bipolar disorder he thought social care was something that was just for older people, he didn’t know it might apply to him. But being referred for a social care assessment by his doctor has had a profound impact on Lee’s health and given him the support he needed to stay in work.

12. “I can come across as very articulate; I own and run two businesses. Outwardly I’m completely normal; I’m not wearing a plaster cast that says there’s anything wrong with me. But I can spend three weeks under my bed, hiding from the light. I've not washed, not changed my clothes, not done the dishes and not done any housework - all because I just couldn't.”

Lee

13. “My social care plan helped me to do some housework, join a gym, go walking and develop hobbies. I worked with my social worker to adjust it as time has moved on and I have progressed. Social care has empowered me and given me access to skills to help myself.”

Mind survey respondent

14. “When I wasn’t able to access the care I needed, it impacted hugely upon my quality of life. I became increasing unable to engage with the activities available to me,  it affected my ability to eat, wash and dress, keep the house relatively clean, and had a direct impact upon ‘reckless spending’ as a symptom of my mental health issues. Other than meeting up with my befriender (which can be less than once a month, especially if I’m not well) …without support then I am predominantly housebound.” Mind survey respondent
15. “‘So, practically, without support it is incredibly difficult to leave the house, and I do not speak to anyone, and the more weeks that this happens consecutively then the harder it is to do so again. Before there was any support, it could be anything up to seven or eight weeks in a row of not going out at all.”

Mind survey respondent

16. “I have bipolar disorder, and when I was severely depressed I found it very difficult to get up. My carer would get me out of bed, shower me, help me to dress and sometimes to go on little walks. It made a tremendous difference. My wife has very high blood pressure and diabetes, so sometimes it’s not good for her to have to care for me.”

Mind survey respondent

The impact of separate funding systems and a lack of integration between health and social care

17. The lack of integration and separate funding systems for health and social care means that people with mental health problems often struggle to get the social care support they need. This is illustrated by the complex legal entitlements for people admitted to mental health wards inpatients who may or may not be eligible for health and social care services under a range of different provisions. Examples of this are below:

• Section 117 aftercare: People can get free help and support when they leave hospital (section 117 aftercare) but only if they have been detained under certain sections.
• NHS continuing healthcare: Some people with long-term complex health needs qualify for free social care arranged and funded solely by the NHS. Determining eligibility for continuing healthcare requires people to undergo a complex assessment process.
• Care Act 2014: Under the Care Act 2014, local authorities must carry out an assessment of anyone who appears to require care and support, regardless of their likely eligibility for state-funded care. If eligible, and depending on their financial means, the local authority may have a duty to provide funded social care support.

18. A consequence of the lack of integration between health and social care services is that people with mental health problems are forced to remain on mental health wards when they’re well enough to leave, while waiting for social care services.
19. From April-November 2019, over 40,000 bed days were used by people with mental health problems who were well enough to leave but were unable to because they were waiting for a social care package at home. The cost of these delays was over £16m[8].
20. Some of the barriers to reducing Delayed Transfers of Care (DTOCs) that relate to the lack of integration between health and social care include:

• Too much time spent by CCGs and local authorities on agreeing funding splits for care packages.
• Too much time spent by NHS mental health trusts and local authorities on identifying responsibility for delays. In some areas, this had led to tense working relationships between NHS trusts and local authorities.
• A lack of integration between health and social care teams leading to delays in getting people the support they need e.g. lengthy referral processes leading to delays in Care Act assessments for people admitted to wards.
• A trend away from collaboration and pooled budgets, despite the rhetoric on integration at a national policy level.

21. These challenges may be exacerbated by the changes to social care under the Coronavirus Act, which could make it more difficult to access social care support. For some people, difficulty accessing social care assessments could lead to them being discharged with inadequate support.  For others – particularly those with more complex mental health needs who require higher levels of support in the community - difficulty accessing social care assessments and support may lead to them being forced to stay in hospital when they are ready to be discharged.
22. The UK Government must ensure people with mental health problems can be safely discharged from hospital and that anyone who is discharged has access to health and social care support in the community to enable them to manage their lives and mental health. The UK Government should implement the recommendation from the Independent Review of the Mental Health Act that inpatients are provided with statutory care plans which include records of discharge planning. The review’s call for a statutory duty to be placed on local authorities and CCGs to implement the statutory care plans should also be implemented[9].
23. The UK Government must ensure that any long term funding solution for social care ensures there is better integration between health and social care.

Question 2

What level of funding is required in each of the next five years to address this?

24. The Lords Economic Affairs Committee’s inquiry on social care concluded that to restore care quality and access to 2009/10 standards, addressing the increased pressure on unpaid carers and local authorities and the unmet need that has developed since then, around £8 billion a year in additional funding will be required for adult social care. They identified that more will be required in subsequent years as the population of older and working-age people with care needs continues to grow. Roughly, half of all public funding for social care is spent on the working-age population[10].
25. In the longer term, the threshold for eligibility for state-funded social care should be reduced to ensure that people with more moderate needs who still require social care support, are still able to get the support they need.
26. The role of social care in the prevention of mental health crises and supporting people to stay well should also be recognised in any funding model[11].

Impact of coronavirus

27. The impact of coronavirus on people’s mental health, as well as access to services, may contribute to increased social care need. For example, the emerging findings from our recent survey found that almost 60% of people had experienced worse mental health since the coronavirus outbreak[12]. Funding for social care must address rising demand and backlog of people requiring support who may have struggled to access it, as a result of the coronavirus outbreak.
28. The recent suspension of key local authority duties in relation to social care - introduced under the Coronavirus Act – also risks making it more difficult for people to access vital support with undertaking day-to-day activities. This could contribute to more people experiencing a mental health crisis and requiring higher levels of NHS and social care support.
29. Emerging findings from our survey of people’s experience of the coronavirus outbreak (March-May 2020) found that 1 in 5 adults with mental health problems had tried to access services during the last four weeks. A quarter of adults had been unable to do so. Mind is analysing additional data on the impact of coronavirus on social care support for people with mental health problems, which we will be happy to share with the Committee.
30. It is also the case that many people with mental health problems do not have people to rely on if they are unable to receive support from voluntary and/or statutory services. People with severe mental health problems can be more likely to experience loneliness and isolation and to have limited support and social contact with other people. Having a severe mental health problem also means you are at an increased likelihood of not having informal sources of support – either from friends and family, or from the local community (Crowley et al, 2019)[13].

Question 3

What is the extent of current workforce shortages in social care, how will they change over the next five years, and how do they need to be addressed?

31. As part of UK Government’s plan for social care, it must set out how it intends to tackle high levels of vacancy rates in the adult social care workforce.
32. There is a need to implement policy changes which will improve working conditions for social care workers and address issues around staff retention. Skills for Care’s 2018-19 annual report found that the adult social care staff turnover rate was almost 40% and had risen for the sixth year running. Staff were more likely to leave their role if they were lower paid and had higher rates of sickness[14]. The annual cost to employers of poor mental at work is between £33 billion and £42 billion (with over half of the cost coming from presenteeism – when individuals are less productive due to poor mental health in work) with additional costs from sickness absence and staff turnover[15].
33. It is crucial that there is improved support for the mental health and wellbeing of social care workers, who are under pressure like never before. It can be particularly challenging for people to prioritise their own mental health when caring for others in such a difficult situation.
34. Mind is calling for the UK Government to implement the following changes to Statutory Sick Pay to support people both currently and post-lockdown:

• The UK Government must urgently increase the SSP rate to match the National Living Wage and Minimum Wage to make sure people can meet their living costs at this time. The current rate of SSP is far too low. £94.25 a week is just 29 per cent of the £328.40 income an individual would receive for a 40 hour week paid at the minimum wage or 26 per cent of the 2018/19 Living Wage rate of £360 for a 40 hour working week.
• The UK Government must expand the eligibility to claim SSP to cover those who earn under £118 a week. Without this, people will be left feeling that they must work, even when directly affected by coronavirus.
• The UK Government must also make sure everyone is able to take the time off sick they need, regardless of employment type. The current crisis highlights the need for people to be able to access support immediately when they become unwell, but self-employed people may be left not knowing what action to take or where to turn for financial support and we’d urge the UK Government to address this.
• Everyone should receive a rate of sick pay which meets their living costs, without also having to apply for benefits. In such a stressful situation, people should not be left having to apply for benefits on top of or instead of sick pay, when the sick pay system should be meeting their needs.
• Longer term, more fundamental reforms are needed to ensure the Statutory Sick Pay system enables everyone to take the time off they need when unwell. Last year, the UK Government consulted on changes to SSP as part of the Health is Everyone’s Business consultation and we would urge the UK Government to respond to the consultation as a matter of urgency as soon as this emergency is over.

35. Mind is also supporting the mental health and wellbeing of social care workers through the ‘Our Frontline’ partnership which offers round-the-clock one-to-one support, along with a collection of resources, to support the mental health of health, care, emergency and key workers.
36. There is a role for UK Government in helping employers to better support the mental health of their employees. Recommendations outlined in the Thriving at work review of mental health and employers include:

• Make it simple for employers to support staff through support and online information platforms and joining up existing provision aimed at employees and employers.
• Set clearer expectations of employers through legislation.
• Do more to prevent and end employer practices which contravene employment and equalities legislation.

Question 4

What further reforms are needed to the social care funding system in the long term?

Reforming social care

37. As a member of the Care and Support Alliance – a coalition of over 70 of the UK’s leading charities advocating care reform - we support their recommendations for a fair care system. After twenty years of promises and stalemate, we need urgent reform to make sure that people have the care they need, when they need it.
38. We want to see a sustainable, strong and secure social care system, which:

• puts working age adults, including those of us with mental health problems, at its heart, alongside older adults and carers
• protects those in particularly vulnerable circumstances, ie low income; without family support
• pools risk on a compulsory whole  population basis, funded through taxation
• provides care free at point of use
• by lowering eligibility criteria and increasing access to social care
• is integrated  with health and social security systems to deliver a comprehensive safety net that is easy to administer, and easy to understand and navigate for those in need of care and their families (and provides advocacy for those needing additional support)
• ensures there is better integration of health and social care

Developing a cross-government approach to mental health

39. It is important that the UK Government begins to prepare for the longer-term impacts of the coronavirus crisis. Our mental health is affected by a huge range of things – the quality and security of our homes, employment status and money worries. All of these aspects of our lives have been adversely affected by the coronavirus outbreak.
40. There is a lack of effectiveness in the UK Government funding health services to help people experiencing mental health problems if, at the same time, there is a flawed benefits system and inadequate social care support which undermines the ability of people with mental health problems to work, live independently, and avoid homelessness. Post-lockdown we are urging the UK Government to develop a cross-government approach to mental health which brings together a coherent strategy to tackling these issues and ensure that all policies are assessed for their impact on mental health.

June 2020

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