Written evidence submitted by Leonard Cheshire Disability [SOC 108]

About Leonard Cheshire Disability

1. Leonard Cheshire Disability is the UK’s leading charity supporting disabled people. We work for a society in which every person is equally valued.

2. We believe that disabled people should have the freedom to live their lives the way they choose, with the opportunity and support to live independently, contribute economically and participate fully in society.

3. At Leonard Cheshire Disability we provide a range of care and support services including residential care, supported living, homecare, day services and specialist care for adults with acquired brain injuries.

4. We also campaign to make care fair for everyone who needs it, including seeking an end to flying 15-minute care visits and sustainable long-term funding for social care.

Overview

5. Social care enables over 1 million disabled and older people in the UK to live independently and contribute to society.[1]

6. Like the NHS, social care is a vital public service. As well as providing people with the essential support they need with basic everyday tasks like washing, dressing and eating, social care enables people to connect with their communities and move into, or stay in, education, volunteering and employment.

7. In addition, high quality, appropriately-timed care and support also reduces avoidable expenditure on healthcare and other public services by preventing, reducing and delaying people’s need for care and support.

8. However we are concerned that significant and sustained reductions in funding for social care since 2010, combined with an inadequate plan to ensure the sustainability of the system over this Parliament means that:

      A rapidly growing number of people who need vital support will be locked out of the system. At least 400,000 fewer people are now receiving social care compared to 2009 - a reduction of 29%[3] - despite ever increasing demand from an ageing population.

      The success of the Care Act 2014 is in jeopardy. There is a growing body of evidence that underfunding is impacting on the ability of councils to meet their statutory duties in relation to care and support, undermining the forward-thinking vision for the system laid out in the Act.

      The stability and diversity of the care market is at risk. In response to this year’s ADASS Budget Survey 80% of Directors reported that providers in their area are facing financial difficulties now.[4]

      Unsustainable additional pressure is being placed on the NHS and other public services. The NHS cannot work effectively without a well-functioning social care system. Over 11,000 people in England have been delayed leaving hospital because of a lack of social care already this year- 37% higher than over the same period last year.[5] 

9. In this context it is vital that the Government and councils take swift action to ensure the sustainability and quality of adult social care over the long term, including:

        Bringing forward planned investment in the Better Care Fund planned for 2019/20 to ensure the sustainability of the system in the immediate term.

        Launching a cross-party commission on the future of health and care to drive forward integration and secure sustainable funding of both systems.

        Putting an end to flying 15-minute care visits for personal care.

        Driving increased spending on preventative support for adults with low and moderate care needs to prevent or delay their needs escalating further.

        Introducing the social care appeals system provided for in the Care Act 2014 to ensure that disabled and older people can challenge unfair decisions about their care and support.

Funding for adult social care and the impact of the 2015 Spending Review

10. Despite a rapidly increasing population of people who need care and support, since 2010 publicly-funded social care has seen funding reductions totalling nearly £5 billion. [6]

11. This year, councils have planned to make savings in adult social care of £941m - 7% of the total net adult social care budget - and most will have to make further savings this year and next. ADASS estimates that the funding gap will continue to be at least £1 billion each year of the Parliament.[7]

12. As a result of these severe funding pressures, access to publicly-funded social care is now severely restricted, and risks becoming a residual service available only to those with the highest needs on the lowest incomes. At least 400,000 fewer disabled and older people are now receiving care compared to 2009.[8] At the same time, those who continue to receive care too often have to accept lower levels of support and a reduced quality of care.

13. These funding pressures have been further intensified by the introduction of the National Living Wage, estimated to carry a price tag of £1 billion by 2020[9], and recent changes to Deprivation of Liberty Safeguards. Both are positive for people using and working in social care, and are welcomed by Leonard Cheshire Disability, but it is vital they are funded appropriately at a time of already severe pressure on the system.

14. Taking into account the combined impact of demographic pressure and additional costs to the system, it is estimated that an additional £1.1 billion will be necessary this year simply to maintain services at current levels.[10] This does not account for those who have lost access to care over the past five years, despite desperately needing vital support.

Social care precept

15. We welcome new powers for councils to levy a 2% social care council tax precept. This gives councils increased financial flexibility and has put an extra £380 million into the system this year.[11]

16. However we are concerned that this is ‘too little, too late’ and is nowhere near enough to sustainably bridge the social care funding gap – estimated to be at least £1 billion per year.[12] To put this is context, direct council costs and increased provider fees related to the introduction of the National Living Wage will cost around £520m (plus at least £92m in further costs associated to the National Minimum Wage) this year[13] – the precept funds less than two thirds of this.

17. The Government estimated that the social care precept would increase adult social care funding by around £2 billion a year by the end of this Parliament. However, this estimate relies on all local authorities choosing to raise the precept every year of this Parliament, on top of general raises for other services, which is extremely unlikely.

18. In its first year, 93% of councils are levying the precept.  That the overwhelming majority of councils have chosen to do so demonstrates their ongoing commitment to delivering their Care Act duties and providing high quality support for their local populations. However, the amount of additional money raised by the precept is insufficient and it is unrealistic to assume that councils will be able to continue to increase taxes in subsequent years.

19. Despite most levying the precept, 40% of local authorities decided not to raise council tax by 1.99% this year and there is no guarantee that the majority of councils will continue to levy the precept itself over the coming years.  The Kings Fund has estimated that the precept will raise closer to £800 million a year by the end of this Parliament, leaving a £1.2 billion gap against the Government’s own assessment. 

20. We are particularly concerned that the precept will raise the least money in areas where funding pressures are most severe, potentially disadvantaging deprived areas which often have the greatest social care need.

21. In this way, the precept risks exacerbating inequality of provision and creating a ‘postcode lottery’ between local authorities.  The Public Accounts Committee recently labelled the precept a ‘complacent’ response to the funding crisis for this reason.[14] 

22. For example, the precept raises an amount equivalent to 2.29% of the adult social care budget for the most deprived quartile of unitary and metropolitan district councils, while for the least deprived quartile it raises 3.66%.[15] 

Better Care Fund

23. We welcome the drive to fully integrate health and social care by 2020 and the Government’s commitment to divert money into social care through an additional £1.5 billion investment in the Better Care Fund by 2020/21.

24. However, with no additional funding planned for 2016/17 and just £105 million committed in 2017/18, social care will continue to struggle in the interim, locking an increasing number of people out of the social care system and resulting in poorer care for those who can still access support. It is vital that this increased funding is bought forward to earlier in the Parliament in the same way that additional NHS funding has been front-loaded.

25. In addition to our concerns about the timing of planned funding increases, we would highlight that the primary purpose of the Better Care Fund is to drive integration between health and social care, not to plug gaps in social care funding. We are concerned that funding that should be used to create cultural and structural change will be forced to act as a ‘sticking plaster’ in a system in crisis. 

26. While closer integration of health and care will undoubtedly offer savings and improve the experience of people using health and care services, it is of concern that increased investment in the Fund is being used to address systemic funding problems in one of the two public services it is aiming to integrate. The Government has specifically proposed that this additional funding can be used to ‘top up’ funding for those authorities that raise less from the social care precept.

27. The phasing of increased investment in the Better Care Fund also means that it will not begin to address the shortcomings of the precept for at least two years. This represents a lack of strategic planning and is in stark contrast to the front-loading of additional NHS funding as part of the Government commitment to increase NHS England’s budget by £8 billion in real terms by 2020/21.[16]

28. While the integration of health and social care has the potential to improve the experience of patients and service users it ‘… is not an answer in itself, or a panacea for the system’s financial challenges.’[17] There is a need for clarity about what integration means and what its financial aims are. The Public Accounts Committee has previously highlighted the lack of clarity about the savings to be expected from integration.[18]

Continued risk to the sustainability of the system

29. Despite the additional funding committed through the Spending Review, overall, it is estimated that there will be a social care funding gap of as much as £3.5 billion by 2020.[19]

30. As a result, in the short term we are calling for the Better Care Fund money earmarked for 2020/21 to be brought forward to help relieve some of the pressures on the system right now.

31. In the longer term, increased, sustainable social care funding is vital to bridge the funding gap. Along with other stakeholders, we believe that the Government should set up a commission on the future of health and social care to ensure that the future sustainability of the system is founded on the basis of a cross-party commitment to increases in the proportion of GDP spent on funding support for disabled and older people.

The impact of funding pressures on people with care and support needs

Restricted eligibility and reductions in preventative spending

32. Recent research conducted by Leonard Cheshire Disability has revealed the detrimental impact that restricted eligibility for social care is having on the lives of people with unmet care needs. The eligibility threshold for publicly-funded social care currently sits at the equivalent of ‘substantial’. This means that people with care needs which are significant but fall below the minimum eligibility threshold often find it difficult or impossible to access social care.

33. For working-age adults, the negative consequences of not receiving enough social care include inability to work; social isolation; loss of confidence; and being unable to pursue hobbies and activities of interest. People also report a significant negative impact on their physical and mental health and more time spent in hospital.

34. Disabled people with moderate needs tell us that even a small amount of help would have a huge impact. People frequently identify support with household tasks, emotional support and mentoring as areas where they have unmet needs.

35. As little as one or two hours a week of support could transform people’s lives by helping them to engage more actively in their local communities and maintain their health and wellbeing. This type of early intervention and support also has significant economic benefits, preventing some disabled people’s care needs from escalating due to stress and isolation and enabling people to get into work, as well as reducing pressures on other public services including the NHS.

36. In recognition of this, the Care Act introduced a statutory duty for councils to provide or arrange for the provision of services, facilities or resources which contribute towards preventing, delaying or reducing people’s need for care and support.

37. However, significant funding pressures are making it difficult or impossible for councils to prioritise this type of investment. This year’s ADASS Budget Survey found that Directors see increased prevention and the integration of health and social care as the two most important ways in which savings could be made over the next three years. However as budgets continue to decline in real terms, it is becoming increasingly difficult for councils to manage the tension between prioritising statutory duties towards those with the greatest needs and investing in services that will prevent and reduce future needs. As a result of this tension, this year councils will be spending 4% less on prevention than last year.[20]

38. Lack of investment in prevention will create future financial pressures. Many people with care and support needs will require low level interventions to maintain independence. Without such support their needs may well escalate and become a greater cost to their local authority and the health service in the future.

15-minute flying care visits

39. Every day, thousands of disabled people receive support with personal care in their own homes, to enable them to wash, dress and eat and to live independently. While short visits can be appropriate where requested or for medication and welfare checks, too many councils are providing people with flying 15-minute care visits for support with intimate personal care including washing, continence care and dressing.

40. This deprives people of their dignity and means that care workers are forced to rush through their tasks without time to provide the personalised care, support, and conversation that is so important. Our research shows that most people who are not disabled need at least 40 minutes to get up, washed, dressed and have breakfast in the morning.

41. Recognising this, statutory guidance accompanying the Care Act 2014 states that ‘short home-care visits of 15-minutes or less are not appropriate for people who need support with intimate care needs’.[21] In addition, the National Institute for Clinical Excellence (NICE) advises that homecare visits should usually be at least 30 minutes long, unless they are for medication or welfare checks.

42. Despite this, our recent research showed that some councils are still commissioning homecare visits for personal care of 15 minutes or less.[22]  Responding to our FOI, at least 18 councils indicated they did commission visits for personal care that were delivered in 15 minutes or less, and a further 23 did not respond to our request for clarification on this issue. Between them, these 18 councils commissioned more than 18 million hours of home care for more than 50,000 people aged 18+ in 2014/15. Altogether, as many as 40 councils in England may still be commissioning 15-minute visits for personal care.

43. This commissioning practice is unacceptable and clearly demonstrates the impact of funding pressures on social care. We are calling for an end to the commissioning of flying 15-minute care visits for personal care.

Access to information, advice and guidance

44. Another area where funding cuts are undermining the success of the Care Act is information, advice and guidance (IAG). IAG is key to enabling disabled people to navigate the social care system and make informed choices about their care. Although councils have a duty under the Care Act to provide universally accessible information and advice services in their local area, disabled people frequently tell us that they are unable to access information and advice. This leaves people feeling frustrated and ‘stuck’ in a system they don’t understand, often at a time of significant stress and anxiety in their lives.

45. We are also concerned that access to specialist advice and support is being cut. This includes support for people receiving direct payments who employ their own personal assistants:

46. Disabled people also tell us that they struggle to access information about how to raise issues with the quality of their care, or to effectively challenge decisions made under the Care Act (e.g. about eligibility or level of personal budget). People who are unhappy with their support are frequently unable to navigate the council’s complaints system or to seek independent redress, leaving them stuck with inadequate or low quality care with nowhere to turn. Funding pressures mean that the independent appeals system provided for in the Care Act has been put on hold.

47. It is vital that the government takes action to introduce an appeals system for social care as provided for in Part 2 of the Care Act. The new appeals system must be independent of local authorities and have powers to reverse unfair or inaccurate decisions. The freeze on plans to introduce a social care appeals system is a clear example of underfunding impeding the success of the Care Act.

Conclusion

48. Existing funding commitments to adult social care are wholly insufficient and unsustainable over the longer term, especially as the population of people with support needs continues to rapidly increase.

49. The impact of this systematic underinvestment is compounded further by the fact that additional funding over this Parliament is not fairly distributed across councils and or across the lifetime of the Parliament.

50. As a result, access to care and support is now severely restricted for many and the quality of support experienced by those who continue to receive care is declining.

51. The impact of this on other public services is acute. Underfunding is undermining the integration agenda in health and care and the sustainability of the NHS.

August 2016