Written evidence submitted by NIHR Policy Research Unit (SCF0051)

This response is structured to reflect the Committee’s terms of reference: it draws in the main from the Unit’s recent studies.

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

We are grateful for the Committee’s interest in exploring this question, however our position is that the social care funding system should not only be seen as relevant to the NHS. The funding of social care impacts on other parts of the public sector and we would caution about it being seen as subsidiary to the NHS. It impacts, for example, on housing and homelessness, on criminal justice, on employment, and on the income support and benefits systems. More broadly it impacts on the nation’s economic wealth and wellbeing – notably in respect of people’s ability to work and contribute to society.

There is much said about the ways in which social care problems – of difficulty in arranging care post-hospital for example - impact on the NHS by delaying discharge. Less is made of the ways in which lack of social care means that families and individuals struggle until crisis point is reached. Unmet need or needs that are inadequately met lead to complications of need and sub-optimal, sometimes expensive, responses. Nowhere is that more evident than in the difficulties facing individuals and families with severe learning disabilities and people with dementia symptoms that are hard to support in community settings. Evidence for the former comes from the events following the Winterbourne View scandal and for the latter from work in which we were engaged that evidences the difficulty facing staff in social care to support residents in distress (see Moniz-Cook et al 2018). Likewise, current difficulties in social care support of people with experiences of homelessness mean that the NHS often faces problems in effective hospital discharge for individuals with severe needs for care and support (Cornes et al 2020) and that early death is tragically common in this group. Our study of homeless people with dementia living in hostels further pointed to the difficulty of accessing social care support on a systematic level to provide a long-term rather than episodic response to their growing needs and disabilities (Manthorpe et al 2019).

We have noted in reference to the Care Act 2014 that people who need social care are sorely affected by reductions in local authority resources and would draw attention to the impact of this on family and friends acting as carers. Day centre places for example have reduced considerably (Orellana et al 2017) despite evidence of their effectiveness. Any discussion of the Care Act 2014 needs to acknowledge the accompanying changes in publicly funded social care funding and eligibility criteria that affect people with care and support needs and carers. Proportionally fewer people are now eligible for publicly funded social care support. Nearly 1.2 million people aged 65 years and over do not receive the care and support they need with essential daily living activities equating to nearly one in every eight older people living with some level of unmet need according to Age UK in 2017. Younger disabled people are also affected. The impact of this is that not only do some people not receive any services, but more people are depending on family carer(s) (often themselves older people). The increasing negative effects that this often brings are highlighted by carers’ organisations such as Carers UK and the Carers Trust. Such pressure may take many forms; many carers are financially out of pocket, their health and wellbeing are negatively affected and deteriorate, and they become socially isolated and lonely. For some there are long-term negative consequences – on relationships, employment and mental health. The impact of financial austerity was particularly clear (Manthorpe in press) in the evaluations of the Care Act’s implementation where cost-shunting – the move of costs falling on one group rather than another – was evident in the increased tendency for short-breaks for carers (respite and similar) that did not incur a financial charge to be seen as a break for the care user and therefore subject to eligibility and means testing thresholds (in other words the care user was being asked to pay for this service which had previously often been free to carers). This suggests the presence of significant tensions involved in balancing the policy goal of maximising carers’ independence through increasing the provision (service) of information and advice, with the risk of undermining carers’ wellbeing by reducing their practical and emotional support. It points to evidence of infrequent assessments and reviews, and of shortfalls in the availability of replacement care which negatively impacts on carers’ wellbeing and labour market (employment) outcomes. To do these tasks and build such relationships needs a skilled and capable workforce.

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

There are many other experts who will provide insight into funding options – and of course it is not simply a question of the amount that will be required but where it will come from and on what it will be spent (with particular needs to lift minimum wage levels and also productivity). There are calls in social care that an equivalent to the NHS People Plan is much needed and dismay that an integrated Health and Social Care People Plan was not commissioned by the Department of Health and Social Care to reflect integration aspirations. The lack of an Arms Length Body for social care would seem to represent a limitation on its ability to command a sense of unity and ability to engage in financial debates. There is an argument for setting out longer financial settlements for local authorities to assist with market shaping responsibilities under the Care Act 2014 and investment in commissioning adult social care, with or without NHS integration.

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?

While social care is a disparate sector there is universal acknowledgement of shortage of staff, high vacancy levels, high inter-employer staff turnover,  management vacancies, shortages of professionals such as nurses but also social workers and occupational therapists and limited access to training funds and career development rewards. Over the next five years the fears of rising unemployment may make the sector more attractive and the Coronavirus pandemic may have raised interest in the sector as providing the opportunity to make a difference although we do not know if the concerns about social care in the pandemic will also negatively affect recruitment. Social care will also be affected by growing numbers of current employees reaching the time in which they wish to retire. Employers will need to acknowledge their ageing workforces.

There is a risk that shortages in the NHS workforce may mean that the NHS looks to social care for staff, with Brexit exacerbating this. There may be scope for agreements that ‘poaching’ of social care staff by the NHS will be seen as immoral in the same way as the NHS commits itself to ethical recruitment internationally. Strong social care providers hold on to staff but still have high turnover that financial reward would help address and possibly registration to counter the impression of being a low skilled sector and to sustain quality and public confidence. Parity of esteem and comparable remuneration systems with the NHS could assist with pathways to make this a reality. Productivity will need to be brought into these debates as will maximising technology and community networks.

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

There is no shortage of proposals for reform so in this brief submission we suggest workforce related considerations. These include discussion of the potential for the Real Living Wage https://www.livingwage.org.uk/ and addressing the problems of precarious employment for social care staff working under zero hour contracts and particularly for staff employed as Personal Assistants (PAs). Our study of PAs has revealed the often precarious nature of their terms and conditions. If we are to maximise the benefits of PA working and PA support for care users then they do need to have employment protection at the very least (Woolham et al 2019). This is a small but growing section of the social care workforce and its benefits must be evident to both its employers and to the workforce. Furthermore, they need to be known to local care systems. We suggest that reform needs consideration in any workforce strategy or plan.


Cornes, M. et al (2019) Transforming out-of-hospital care for people who are homeless. Support Tool & Briefing Notes: complementing the High Impact Change Model for transfers between hospital and home, London: NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King's College London. https://doi.org/10.18742/pub01-007

Manthorpe, J., Samsi, K., Joly, L., et al. (2019) Service provision for older homeless people with memory problems: a mixed-methods study. Southampton (UK): NIHR Journals Library; (Health Services and Delivery Research, No. 7.9.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK537942/ doi: 10.3310/hsdr07090 

Manthorpe, J., Fernandez, JL., Brimblecombe, N., Knapp, M., Snell, T. and Moriarty, J. (2019) Great expectations – ambitions for family carers in UK Parliamentary debates on the Care Bill, International Journal of Care and Caring,

Manthorpe. J. (in press) Care Act Evaluation Summary, London, DHSC.

Moniz-Cook, E., Hart. C., Woods, B., … Manthorpe, J. (2017) Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families. Southampton (UK): NIHR Journals Library.

Orellana, K., Manthorpe, J. & Tinker, A. (2017) Evidence to inform the commissioning of day centres for older people’, Health and Social Care Workforce Research Unit, Policy Institute at King’s; London, King’s College London.

Woolham, J., Norrie, C., Samsi, K. and Manthorpe, J. (2019) Roles, responsibilities, and relationships: hearing the voices of Personal Assistants and Directly Employed Care Workers. London, King’s College London, https://kclpure.kcl.ac.uk/portal/en/publications/roles-responsibilities-and-relationships-hearing-the-voices-of-personal-assistants-and-directly-employed-care-workers(3e1bf2ae-f5b4-4402-9954-091b51c64ba8).html


June 2020