House of Commons - Social Care

Social Care - Health Committee Contents

4 Shortcomings of the present social care system

78. In the course of our inquiry it became evident that the current social care system is no longer fit for purpose. In this chapter we examine the multiple shortcomings which any reform must address. These failings can be found at all stages of the journey that a person might make in using social care; in particular, they relate to:

— lack of information and advice;

— lack of joined-up care;

— limitations and variations in access to services;

— unfairness of means-testing and charging;

— significant demands on carers;

— lack of focus on prevention, rehabilitation and reablement;

— high levels of unmet need;

— variations in quality of care;

— age discrimination.

Lack of information and advice

79. An important precondition of being able to access care and support is having clear information and advice about what services are actually available (both from the local council and from alternative sources) and how to go about obtaining them. Providing good information is particularly critical because of the difficult and rushed circumstances in which social care decisions are often made.

80. The LGA told us about the scale of councils' efforts to fulfil their obligations in this regard:

Despite [financial] pressure, councils are spending, on average, £1.98 million—or £294.2 million in total—(2007-08) on adult social care that people can access when they need it and without a formal assessment, such as information and advice services.[86]

81. However, the availability of such services is clearly very variable. The Parkinson's Disease Society (PDS) told us about:

poor information provision and signposting to services, especially with regard to signposting to social care support […] over half (52%) of carers [in a survey] identified "getting expert advice on health and social services"; as "very important", but only a fifth (20%) were actually receiving this, and only a third of carers were aware of their right to a carers' assessment.[87]

Similarly, we heard from Mencap, the learning disability charity, that:

one of the greatest barriers to social care is the lack of information and support to the individual and the family. This includes a failure to provide accessible advice and information and often a complete failure to provide any information and support.[88]

Lack of joined-up care

82. The social care system has a complex and difficult interface with other forms of state care and support:

— Non-means tested, non-contributory cash benefits for disabled people and carers are provided by the Department for Work and Pensions (DWP).

— Housing support services are administered locally by councils[89] (with supported/sheltered housing the joint responsibility of housing and social care services). These services are now substantially provided through Registered Social Landlords in the independent sector.

— Free health care is provided by the NHS, whose relationship with the social care system is of fundamental importance but has long been recognised as especially problematic.

In 1998 our predecessor committee identified multiple barriers to the two systems working together;[90] some of these problems have been mitigated but none of them has been eliminated.

Differences in assessment processes, eligibility criteria and means-testing arrangements between these forms of care and support result in a system that is confused and highly complex, with people too often receiving disjointed and ill-coordinated support.

83. The Alzheimer's Society reported that people with dementia and their carers "can experience great frustration and poor quality services where joined up working is not as effective as it should be".[91] Macmillan Cancer Support told us that cancer patients were too often not even assessed for social care needs "as a result of little or no joined up working".[92]

84. We heard from Home Group Limited, a provider of supported housing services, that:

Many clients with multiple and complex needs and/or dual diagnosis (eg mental health issues and substance misuse) are still subject to funding battles between health and social care services and frequently end up "falling between two stools" with their needs unmet until such disputes are resolved.[93]

The mental health charity Mind also reported that people with complex needs were ill-served because "Mental health problems do not fit neatly into 'health' and 'social care' issues" and the two were poorly coordinated.[94]

Limitations and variations in access to services

85. Rationing by eligibility criteria excludes many people from access to services. In 2008, the annual report on The State of Social Care by the then regulator for social care, the Commission for Social Care Inspection (CSCI), highlighted the situation of people "lost to the system" when they failed to meet local eligibility criteria for social care.[95] The report expressed concern that FACS was being used crudely to curb demand, with damaging consequences for vulnerable people.[96]

86. CSCI was subsequently commissioned by the Government to undertake a full review of eligibility criteria for social care, and the resulting report, Cutting the Cake Fairly, was published in October 2008. CSCI found that some three-quarters of councils were not providing access to services for people with Low or Moderate needs.[97] (The Secretary of State for Health, Rt Hon Andy Burnham MP, acknowledged in evidence to us that he had been advised that "only one council in the country provided support in all care categories".)[98]

87. The CSCI review identified multiple problems with the current system of eligibility including:

— lack of clarity and transparency;

— lack of fairness;

— service-led rather than needs-led approaches;

— limitations of a risk/needs based model;

— insularity and fragmentation;

— marginalisation of prevention and inclusion agendas;

— inadequate approaches to diversion and signposting; and

— tensions between FACs and the personalisation of care and support.

88. Although FACS was intended to address concerns about a "postcode lottery" in the assessment of eligible needs, it has clearly failed to do so. Variations in eligibility thresholds can make it very difficult for people with social care needs to move from one part of the country to another, since in doing so they may lose their entitlement to care and support. The same applies to the fact that assessments are not "portable" between local-authority areas, meaning that a person can receive different assessments of need from different councils.[99]

89. We received evidence that eligibility criteria pose a particular problem for people with fluctuating conditions. For example, people who have the relapsing/remitting form of MS often find that they do not meet eligibility criteria if the assessment is undertaken as a "snapshot" rather than taking account of their needs over a period of time.[100]

90. We also heard that "resource allocations" (i.e. the sums of money available to meet each person's needs) are often low and vary excessively by area, relative to unit costs, leading to variations in service levels. This too can make it difficult for people to move to a different part of the country. Where resource allocations are low, care and support can be limited to personal care, excluding help with other activities of daily living (such as shopping, cooking and cleaning). Where support is being provided through Direct Payments, people can find they need to "top up" with their own money in order to meet their needs properly.[101]

Unfairness of means-testing and charging

91. In Chapter 2 we outlined the current systems of means-testing and charging for residential and non-residential social care. Below we look at how these can be unfair and inconsistent in their impact on people with care and support needs.

RESIDENTIAL CARE

92. The vast majority of property owners will have assets in excess of the upper capital limit for the residential care means test (as we have noted, this is uprated annually and in 2009-10 is set at £23,000). When the statutory means-testing rules for residential care were originally established, in 1948, relatively few older people owned significant assets, including property, but this is certainly not the case now. In consequence, means-testing now affects many more people than it once did. In future, many more older people will potentially be affected by means-testing, due to the ageing of large population cohorts (the "baby boomers") with even higher levels of owner-occupation than there are among older people at present.

93. The way that the means test operates means that there is a "cliff edge" effect. Anybody with assets valued at more than £23,000 (in 2009 -10) finds that if they need residential care they receive no help at all from the state and they could be faced with unlimited, potentially catastrophic, costs. The Green Paper points out that 20% of people with care and support needs over the age of 65 will require care costing more than £50,000, whilst:

An average stay in a care home is about two years, and this can cost over £25,000 just for the cost of care; accommodation can cost as much again. But someone with a long-term condition such as Alzheimer's disease could need several years of residential care and so could face far higher costs than this. Just four years of care and accommodation in a care home could cost over £100,000, and some people need residential care for more than ten years.[102]

According to evidence that we received from Partnership Life Assurance Ltd (citing research by Laing & Buisson):

with the estimated average stay in a care home at around four years and with the average annual fees for residential care for 2009-10 being £24,908 increasing to £34,788 if nursing care is required, this could mean an average cost of £139,152. It should also be noted that one in ten people in care will live for eight years. Inevitably the cost of care is not static. This year's figures have increased by 5.1% and 3.3% respectively from last year. Many care homes can cost more than £50,000 per year.[103]

94. The fact that the relative value of property has risen considerably, particularly in the past decade or so, means that people are expected to pay much greater sums than in the past as a result of means-testing. According to the house price index published by the Department for Communities and Local Government, "Between 1997 and the peak in the summer of 2007 average UK house prices rose three-fold from £74,200 to £219,256".[104] Since then, prices have fallen; but the average price in the third quarter of 2009 still stood at £197,277.[105] According to the insurance firm Partnership Life Assurance Company Ltd, the average amount of equity in property held at the age of 85 is £190,000.[106] The effect is all the more acute in London and the South East, where house prices, and care home fees, are the highest.

95. It is unlikely that many people will have to spend the entire value of their assets on residential care (given the average length of stay in a care home and the level of property prices).[107] However, large numbers of people face the prospect of having to sell their home (or to undertake private equity release or council deferred payment arrangements, which would mean their property being sold after their death),[108] to raise the substantial funds needed to pay for care. Their prospective inheritors, meanwhile, stand to lose a significant part of their inheritance. This situation has long been resented, for several reasons.

96. Many people mistakenly believe that social care is available free, on the same basis as the NHS, and are angered to find, when they actually have to deal with the social care system, that it is not.[109] The complete lack of help for people with relatively modest savings or property assets is seen as punishing the thrifty and prudent, while the feckless and improvident are rewarded. The latter point may well be unfair,[110] but the prevalence of this view illustrates how the lack of universality in service provision can undermine social solidarity. People are likely to resent paying through their taxes for a service they themselves are not able to use and to stigmatise those who are eligible.

97. Most people expect to be able to leave their assets to their children or other inheritors and find it unjust if their ability to do so is restricted. It could be argued that property values nowadays substantially represent "windfall" gains (made partly at the expense of younger people without property assets), and that inheritance too is a form of lottery. However, another lottery (in care costs) is clearly not a fair mechanism for redistributing good fortune: the lack of "risk pooling" leads to significant "intragenerational inequity", since older people with assets who are fortunate enough not to need residential care do not stand to lose anything.

98. There are other forms of unfairness in the system too. Because the statutory means test sets cash thresholds that are uniform across the whole country, it does not take account of local variations in asset wealth (caused by local variations in property prices). Likewise, the statutory rules on charging for residential care do not take account of local variations in the cost of providing care, the amounts different councils are prepared to pay or the expensiveness of the care provided in each individual case. This means that the proportion of the cost of providing residential care that is recouped in charges can vary between areas. While across England 29.6% of gross expenditure on residential care for older people was recouped in charges in 2007-08, it was as high as nearly 50% in some areas and as low as under 10% in others.[111]

99. In addition to user charges, people can experience pressure to pay top-ups (paid in addition to local authority standard rates)[112] as a form of hidden user surcharge in order to access an appropriate or adequate quality of service or to have any choice of provider. Citizen's Advice told us:

It is unfair that [local authority] sponsored residents or their families often have to pay top up fees to obtain suitable residential care[113]

100. However, Sheila Scott, the Chief Executive of the National Care Association, argued that top-ups served only to buy a premium service:

Q478 Dr Taylor: […] What is the role of these top-ups for enhanced care at the moment? How important is it for the businesses and the income?

Ms Scott: The statutory directive says that people should have choice, and the only criteria attached to that is around cost. So there will be some people who the local authority will fund, but their parent wants to go into a more expensive home and they pay the difference. That is one way. Many local authorities accept top-up, providing they can see what the extra service is. So it might be gold taps and a sea view. It might be that. It often is.

Q479 Dr Taylor: Better food; does that come into it?

Ms Scott: No, absolutely not. I think that is one of our big fears: that there would be this differential in service. Within a care home everybody would get that same service—the same food, the same service—they would be paying for some sort of extras, or the cost of the service is that much extra where it is above the local authority limit.

Q480 Dr Taylor: As opposed to a sea view, it could be a single room rather than a shared room, those sorts of things?

Ms Scott: Yes.

NON-RESIDENTIAL CARE

101. Charging for non-residential care, where councils have considerable discretion, also shows great local variation and can effectively operate as a further "postcode lottery".[114] On average, councils recoup 11.8% of homecare expenditure in user charges. Eight authorities currently provide all homecare free of charge. At the other extreme, four recoup more than 25% of gross homecare expenditure in charges.[115]

102. The National Pensioners Convention told us it had found in a survey significant local variations in the amount charged for an hour of domiciliary care. Over 60% of respondents were being charged between £11 and £15 per hour, more than 20% of them above this range and under 20% below it. The survey found that "in one London borough the charge for home care was £17.50 an hour, in another it was £25".[116] Some of this variation in charges may reflect variations in costs of providing services in different locations, but the impact on people who use services is arguably inequitable and can be a disincentive to seeking help. A survey by the Coalition on Charging in 2008 found that:

80% of the people who no longer used care services said charges played a part in the decision to end using services. A fifth (22%) of people using services suggested they would stop if charges rise.

29% of individuals did not feel their essential expenditure (related to impairment/health condition) had been taken into account in financial assessments to pay charges. Another quarter (23%) believed that only some of their essential costs were considered.

[…]

Three quarters (72%) of individual respondents and 81% of organisations said the Government should consider care service charges in care reform. 59% of individuals and 77% of organisations also believe the Government should consider ending charges.[117]

103. The current system can have a particularly deleterious impact on working-age adults with care and support needs, leading them to find themselves in a "poverty trap". Under the means test they tend to receive their care free of charge, on the basis of having no (or a low) income and no significant assets. Fear of losing this free care can prevent them from accruing savings and discourage their families from leaving them any inheritance.[118]

Significant demands on carers

104. As noted above, since 1948 there has been no legal presumption of a duty on anyone to provide unpaid, voluntary care for family members. Where people are acting as carers, however, their experience of support from local authorities is often poor. In practice, where care is available from family members and others the amount of formal care provided is likely to be significantly lower than it would otherwise be. Raphael Wittenberg, of the PSSRU, told us that data from the GHS showed this clearly:

after controlling for people's age and disability, taking that into account, people living alone are more likely to get care than, say, a married person living with their spouse or a married couple getting help from adult children.[119]

105. Mr Wittenberg told us extrapolations from GHS data indicated that:

roughly 1.75 million out of two million disabled older people in private households […] receive informal care […] mainly from a spouse or an adult child.[120]

The monetary value of care and support from carers (i.e. what it would cost for the same service to be provided by salaried careworkers at market rates) for both adults and children in England has been estimated at £70.5 billion per year.[121]

106. In 2001 the Census included, for the first time, a question on the provision of unpaid care. The Census returns indicated that there were nearly five million carers in England, many of them aged over 65.[122] According to data from the GHS, "In England in 2006, about 16% of women and 8% of men aged 50-64 had looked after someone in the week previous to being interviewed […]"[123]

107. While family members and others would provide care for loved ones whether or not formal support was available, many carers feel that they are not being fairly supported as a result of the inadequate scope of social care. Although they wish to continue caring, many feel the care system too often expects them to do so without respite or other support.[124] Census and other data indicate that significant numbers of people are providing care for more than 50 hours each week. There are particular concerns about care provided by young carers (those aged under 18, sometimes young children) and by very old people (usually spouses).

108. Richard Humphries, Senior Fellow in Social Care at the King's Fund, made the important point to us that presuming too much upon care by family members and others is actually not cost effective:

expectations are too heavy, too unrealistic and that leads to breakdowns in care arrangements which could be avoided. Actually it would be much better from a preventative point of view to provide good support to carers in the first place because that is the most cost-effective and appropriate way of meeting their needs.[125]

109. The demands of providing care and support can have serious effects on carers (including harm to their own health, wellbeing and living standards) as well as on wider society (for instance as a result of carers not being able to maintain their employment).[126] Mr Lloyd told us:

Certainly there is hard quantitative evidence that excessive informal care provision does impact negatively on people's outcomes, whether in terms of quality of life or health […]

According to research findings:

individuals who provided more than 20 hours of care per week particularly to a partner - this is in the older population - did show a statistically significant lower quality of life than equivalent non carers.[127]

Lack of focus on prevention

110. The social care system primarily deals with existing social care needs, rather than seeking to prevent needs developing in the first place. There is too little focus on rehabilitation and "reablement" (helping people who have been ill to recover as much health and independence as possible) in situations such as following discharge from hospital.[128]

111. Rationing by eligibility criteria often means that the system tends to deal with higher levels of need, typically intervening in a crisis situation, but does not seek to prevent these developing from unmet lower-level needs. Sophie Corlett, of Mind, told us:

Getting into the system: it is only accessible at the point of crisis generally or when people are really very unwell. Prevention is not something that social care is really contributing to at the moment.[129]

As such, the system can aptly be characterised as "penny-wise and pound-foolish".[130]

High levels of unmet need

112. Lack of information and advice on social care services, extensive rationing by eligibility criteria and high user charges all mean that many people are prevented from accessing some or all of the care and support they need. However, quantifying the scale of this unmet need is not straightforward.

113. Since there is a duty on local authorities to assess need in this way, it might be assumed that data relating to such assessments of support needs should be available. Comparing this with data on services actually provided could give some indication of unmet need. Such a measure would not, though, be comprehensive, given that not everyone with an unmet need will have sought local authority help (because they are unaware that help is available; or they do not know how to access help; or they do not believe they will be entitled to help; or they do not themselves realise they have a need). Another complicating factor would be the extent to which local authority assessments are "carer blind" in their assessment of need (i.e. made without regard to the availability of carers).

114. However, even this limited means of measurement is apparently not available nationally. John Bolton, Director of Strategic Finance in Social Care at the DH, told us that not all local authorities recorded "data as to those people that they have assessed as to which [FACS] category they fitted into: critical, substantial, moderate or low".[131] We also received evidence that, in some cases, councils apply the financial means test before they have carried out any assessment of need, despite clear guidance from the DH that this should not be the case.[132] The Secretary of State told us he thought it unacceptable for councils to turn people away without recording their needs and argued that local authorities had a duty "to ensure that an overview is taken of levels of unmet need in the community".[133]

115. On the basis of this lack of data, Mr Bolton told us that nothing was known about the extent of unmet need:

Q34 Dr Stoate: […] Do we have any idea of the levels of unmet need?

Mr Bolton: No.

Q35 Dr Stoate: None at all?

Mr Bolton: No.

Q36 Dr Stoate: So we have no idea what is out there.

Mr Bolton: No-one collects that data.

116. Mr Behan observed that CSCI had tried to quantify unmet need.[134] The Commission provided the following estimates in The State of Social Care in England, 2006-7:

— the total number of older people who receive no services and have no informal care, despite having high support needs, is around 6,000; and 275,000 older people with less intensive needs

— in the current system, 1.5 million people (60% of the total number of older people with any disability or impairment) have some shortfall in their care if it is assumed they do not have any informal care; this goes down to 450,000 people if we assume the support of family carers

— if we focus only on older people with high needs, and who receive family carer support, 50,000 people out of 850,000 have some shortfall in their care.[135]

However, Mr Behan also told us that there were no reliable data, as "there has been no research on unmet need which has been verified, no randomised controlled trials".[136]

117. The Secretary of State did, though, quote to us with some confidence further estimates of unmet need:

We do have an idea. I think the up-to-date figure is that there are about 300,000 people with substantial needs.

He said that, if the social care system were not reformed, "The estimate is that the number of people with unmet needs will go up to 400,000".[137] These figures have been calculated for the DH by the PSSRU.[138] They assume a benchmark level of support equivalent to the average packages of care currently provided. This means that only people with need levels that would entitle them to state support in the present system are assumed to have needs and thus potential "unmet" needs. The figures are calculated on a "carer sighted" basis, so they only count need as unmet if it is not being met by either formal or care and support from carers. The projected rise in the level of unmet need is due to demographic factors (a projected increase in the number of older people), as well as the fact that in future greater numbers of older people will be excluded from state support by means-testing due to property ownership.

118. On the question of unmet need where carers are involved, Imelda Redmond, the Chief Executive of Carers UK, explained that there were clearly many cases where carers were receiving no support from social care services:

We know the number of people who are providing care, family carers. We know that there are 2.5 million doing 20 hours a week or more, and we know that there are between 1.7 million and 2 million people receiving social services support across all age groups. You can see a gap there and some of those will be counted in that other number, because they are getting some support, so there is quite a bit gap there.[139]

Variations in quality of care

119. We received evidence that the quality of care and support can be poor. Below we look at evidence of poor quality care, the regulator's view of standards and possible reasons for poor quality.

POOR QUALITY CARE: THE EVIDENCE

Shortcomings in homecare

120. Several witnesses highlighted the problems created by the apparently widespread practice of commissioning homecare visits lasting just 15 minutes, seemingly as an economy measure. Mr Nixon, from the MS Society, told us:

Fifteen minutes is fine for a non-disabled person to wash their hands and face and get themselves sorted out, but the issues are that when you then have someone with a disability who has a complex set of needs, they might need to move slowly, they might need to be encouraged and supported during what they are doing, 15 minutes is a nonsense. It is a 45-minute issue to get somebody out of bed and get somebody sorted out in the morning.[140]

121. Another aspect of homecare that causes difficulty is high turnover of staff, with around a fifth or a quarter of the workforce leaving each year. This, along with use of multiple providers, can undermine continuity of care, compromising quality. High turnover tends to mean that staff are too often untrained; and such training as homecare workers do receive is usually just "on-the-job training".[141]

122. Inflexibility and lack of personalisation can be the most frustrating aspects of homecare for people who use services, for instance having no choice over what time they get up or go to bed. One memorandum of evidence we received mentioned the possibility that a care worker might be "putting [a client] to bed at five in the afternoon";[142] a witness told us about people "being expected to go to bed at 6.00 in the evening or get up at 10.00 in the morning".[143] Considerable logistical difficulties can confront homecare agencies in trying to organise staff rotas, which results in people being visited at unacceptable hours. The desire for flexibility in this is often identified as a reason for employing a PA rather than using standard services. A survey in 2008 found that "A third (34%) of individuals described having no choice over the support services they used."[144]

Shortcomings in residential care

123. Lack of choice and insufficient personalisation are also problems in residential care, as we heard from Stephen Burke, the Chief Executive of the older people's care-advice charity Counsel and Care:

simply again not enough notice is taken of residents' wishes, in terms of their choice of activity, timing of when they eat, and so on, let alone respect of their own culture and food and things like that.[145]

124. There are particular concerns about the quality of residential care for people with dementia. A steady stream of disconcerting anecdotal evidence seems to indicate that, too often, while people's physical needs are catered for, their specific needs arising from their dementia can be poorly addressed.[146] While we were conducting our inquiry, disturbing allegations of overmedication and inappropriate use of tube feeding of people with dementia in care homes were published.[147]

125. Yet there is a wealth of evidence to show that the quality of life for people with dementia can be greatly enhanced by treating them in a person-centred way, according them dignity and respect, regardless of their level of disability or dependence. Symptoms of dementia can be accommodated, whilst providing an environment and experiences that are stimulating and life-enhancing, and allowing opportunities for autonomy, independence and interaction with other people.

THE REGULATOR'S VIEW OF CARE STANDARDS

126. The quality of social care has been regulated, in various ways, for some time; and the scope of regulation has increased significantly in recent years. Below we examine what evidence from the regulators reveals about the quality of care.

Regulation of adult social services departments

127. Annual quality ratings for local authority social services departments have been published since 2002, with responsibility for them passing to CSCI's successor, the Care Quality Commission (CQC), in 2009. Ratings on current performance now use grades of "Performing excellently", "well", "adequately" or "poorly", in respect of each of seven outcomes[148] and of "Delivering outcomes" overall.

128. In December 2009, CQC published its assessment of the performance of 148 local authorities for the year to March 2009, along with an analysis of commissioning. The Commission reported that:

nearly a quarter of councils need to improve significantly in personalising care, to give people who use services more choice and control over their care. And about a third of councils should be doing a lot more to give people greater dignity and respect—including improving arrangements for safeguarding people [i.e. protecting vulnerable adults from potential abuse].[149]

However, the ratings show overall improvement on the previous year, as the ratings have shown every year since their inception. The President of the Association of Directors of Adult Social Services (ADASS), Jenny Owen, told us, on a day when the publication of the latest CQC ratings had attracted adverse media coverage:[150]

There are now no poor councils for the first time ever[151] and 95% of good councils [i.e. performing "well" or "excellently"]. That should have been the headline but it was not. There are eight adequate councils. I would be very worried about that performance. There would have been some very significant work going on between the Care Quality Commission and those local authorities from the time that they were assessed in that way, which was back in the summer […][152]

Councillor Sir Jeremy Beecham, Vice-Chairman of the LGA, likewise said: "The poor are no longer with us, so to speak. I think Jenny said to me before, 'Adequate is the new poor.'"[153]

129. When we asked Baroness Young, the then Chairman of the CQC, about the reliability of the regulator's ratings of local authorities she told us:

I think we have an effective process of working with councils to identify the ones who are not commissioning as well as they should […] We meet with them on a regular basis, we develop joint action plans with them, we monitor whether they are achieving those action plans […][154]

Regulation of providers

130. The publication of quality ratings for social care service providers (both in-house services and independent sector contractors), based on inspections, was begun in May 2008. CQC also took on responsibility for these when it replaced CSCI in 2009.[155]

131. When we heard from the then Chairman of the CQC, Baroness Young, she told us that "about 3,700 services"—the correct figure is actually 4,499 (18.4% of the total)—fell into the "poor" and "adequate" categories in the latest ratings:

that is not acceptable, so there needs to be action on these poor providers to get them further up the quality spectrum.

However, she emphasised that:

Generally speaking, performance has been improving for particularly residential care services over the last few years and performance against the national minimum standards has risen […] for six years in a row.[156]

132. Ms Owen told us that providers' poor performance can be down to temporary fluctuations in standards. In such circumstances the solution is not simply for local authorities to stop commissioning services and remove residents. It would be completely inappropriate to disrupt the lives of residents by doing this instead of working with providers to "try to drive up [their] standards".[157]

133. When we asked Baroness Young about the danger of regulation being merely a "tick box" exercise, she told us:

I have been very impressed […] with the quality of the inspection of services, but, as you know, we have got a new registration system coming in and we are particularly keen to build on the expertise that has been developed over time in inspecting services to make sure that the inspection process is as effective as possible and focuses on the things that people really care about—the outcomes, whether they are treated with dignity and respect, whether their rights are respected, as well as a whole variety of other issues—and we want to very much focus on whether the care that people get is what they should have the right to expect, in terms of what it does for them, rather than simply looking at processes and policies, which can lead to a bit of a tick-box approach.

134. A new unified health and social care regulatory system is being implemented this year, with registration requirements (which are expected to replace the current National Minimum Standards for social care)[158] coming into force on 1 October 2010 for adult social care providers.[159] The CQC will have new powers of enforcement and intervention, including cancellation of registration. It is also planning to introduce quality assessments that will complement its new registration process by providing independent information about the quality of care.

POSSIBLE REASONS FOR POOR QUALITY CARE

135. A number of reasons for poor quality care were put to us in the course of our inquiry. Below we consider these and the evidence for them.

Business discontinuity

136. Ms Owen told us that:

One of the main reasons why homes go in and out of ratings is because they might lose their home manager or the domiciliary care manager, and the manager has a very big impact on the quality, and it can be temporary.[160]

We heard a similar view from Baroness Young, who told us there was evidence that poor quality was often associated with "change of manager" and "change of owner".[161]

Underfunding of providers

137. Until the 1980s, the majority of social care, both residential and domiciliary, was directly provided by local authorities themselves. Since then, however, local authorities have become, either willingly or as a result of central government policy, increasingly commissioners rather than providers of services. Services are now usually contracted out to the independent sector, made up of both voluntary sector and for-profit providers. Since the 1990s, larger for-profit providers have become prominent in parts of the residential care market, with very large corporate concerns emerging, some backed by private equity investors.

138. It is a common complaint of independent sector providers that they are underfunded by local authorities which relentlessly drive down contract values by capping prices below the cost of service provision and awarding contracts to the lowest bidder in a highly competitive market. This obviously constrains providers' ability to provide a quality service.

139. In 2007-08, average unit costs for a place in a local authority care home were £716 per week, compared to £420 per week in an independent sector residential care home and £467 in a nursing home; there were significant variations between councils, particularly in respect of local authority care homes.[162] Mr Laing told us that Laing & Buisson had calculated that "for a provincial residential home outside the London area £540 a week would be a fair fee […] and £670 a week for a provincial nursing home".[163]

140. Average gross expenditure per hour on homecare in 2007-08 was £14.45; again, there were significant variations between councils.[164] Colin Angel, of the UK Homecare Association, told us:

when councils provide a homecare service they are currently doing that at a gross average hourly rate of £22.30. The same figure for the independent sector is £12.30. So we are operating, we believe, in a situation where costs are at an absolute minimum and we do not think there is much to squeeze.[165]

141. The Association identified as a particular problem the use of "e-tendering",[166] arguing that this led to "a 'Dutch auction' approach, where care contracts are won by the lowest bidder", which "then impacts on pay levels and exacerbates recruitment and retention difficulties."[167] Likewise, we heard from Martin Green, the Chief Executive of the English Community Care Association, that e-tendering:

has been something which we have identified as being a real problem within the sector although of course we did identify it and we got some good support from people like Baroness Young, the Chairman of the Care Quality Commission, who condemned it, and likewise some people in local authorities and in the Department of Health. It seems to me absolutely outrageous that you would set the goal of delivering high quality care, go through a tender process and then do a Dutch auction. I can understand why you might do that if you are buying a commodity like a pen for a local authority but certainty not in the arena of personalised care services.[168]

142. Nestor Healthcare Plc-Social Care Division told us that in cases where "the contract would not be financially viable in terms of being able to deliver quality services for the price set by the local authority", it had "withdrawn from the tendering process rather than compromising the quality of service provision".[169] Similarly, we heard from a voluntary sector provider, Sue Ryder Care, that in some cases it:

has chosen to withdraw from the bidding process as the parameters within which we would have to operate under the contract would not enable us to provide a quality service. In the case of Walsall, after Sue Ryder Care removed itself from the process the next two incumbent service providers were suspended by CSCI.[170]

143. Baroness Young told us there was evidence that "major cost reduction programmes" were associated with lapses in quality.[171] Further evidence of underfunding is apparently provided by the need in some cases to pay top-ups to get a good standard of care, which we have already noted. The same can be said of the fact that self-funding care home residents can pay significantly more than council standard rates for an equivalent standard of care, which is often seen as evidence that self-funders are effectively subsidising council-sponsored residents.[172]

Alleged profiteering

144. Considerable profits are made by corporate social-care providers. Recent financial results from the largest commercial care home operators in the UK show annual rates of profit on one measure as high as 28% of turnover.[173] Representatives of the larger providers insisted that very high headline figures were too easily misunderstood because of the complexity of the businesses concerned.[174] William Laing, of the leading industry analysts Laing & Buisson, told us that the prevalent rates of return were what the capital markets deemed to be a "reasonable profit level" and were justified "because running a care home is a moderately risky business".[175] Colin Angel, of the UK Homecare Association, emphasised that without a return on investment the private sector would not be interested in supplying services. He denied that "profit is squeezing quality down", maintaining that "the purchaser would be far more likely to be responsible for that".[176]

145. However, UNISON, which represents many social care workers, insisted that there was a clear link between the profit motive and poor quality, and that "the advantages of in-house provision when it comes to reliability, accountability and quality" should be recognised.[177] Sampson Low, a National Policy Officer for the union, told us:

put plainly, the profits for shareholders are funds that are simply not available for care and if services are further sub-contracted, as they often are, to other providers, agencies and others, then there is a sort of second and third tier of profit margin that has to be found.[178]

146. Mr Low denied that this claim was based on no more than UNISON's ideological bias against the private sector and he was backed up to an extent by Baroness Young:

Could I break the habit of a lifetime and support UNISON slightly with some figures that we have got from our inspection processes about the comparative quality between council-run services, voluntary-run services and privately run services? I do not think the gradient is huge, and this is an art rather than science, but council services have got the largest proportion of good and excellent ratings at 87%, voluntary sector services at 86% and 74% for privately run services.[179]

147. The same type of quality gradient between for-profit and non-profit providers was found in a review of evidence from nursing homes in a number of countries outside the UK, recently published in the British Medical Journal. However, the authors noted that "Many factors may […] influence this relation in the case of individual institutions"; and they identified the need for further research.[180]

Staffing issues

148. Whether as a result of low tender prices, excessive profits or other factors, we heard that low wages, lack of training and career-development, inadequate staffing levels and high staff turnover are significant factors in undermining quality.[181] At the root of this seem to be extremely low levels of pay, allied with very low status,[182] meaning that to be a care home worker one must be either "altruistic or desperate".[183] Data from Skills for Care[184] show that the median hourly pay rate for a care worker in England (at December 2008-February 2009) is £6.56 per hour. There is significant regional variation, with the rate in some regions as low as £6.00. There is also variation between care settings: in residential care homes the median hourly rate is £6.48; in nursing homes it is £6.10; and in homecare it is £6.80.[185] UNISON told us that where homecare workers were paid per call, rather than a straightforward hourly rate, they could earn as little as £5.40 an hour overall,[186] i.e. below the current (2009-10) National Minimum Wage of £5.80 per hour for workers aged 22 years and older.

149. Migrant workers are a key part of the care home workforce.[187] A recent Oxfam report claimed that migrant workers were being exploited by some care homes, with employers often paying less than the minimum wage;[188] this was, however, denied by the care home owners' representatives who gave evidence to us.[189]

Age discrimination

150. Many of the shortcomings in social care appear to relate to inherent and pervasive ageism in the system. Mr Wittenberg told us about the work done by his PSSRU colleague Professor Julien Forder for the DH on the issue of alleged age discrimination in social care:

Analyses of two datasets, the British Household Panel Survey (BHPS) and the national evaluation of Individual Budgets (IBSEN), showed indications of differences in levels of support between age groups after accounting for differences required to compensate people with varying levels of need (e.g. disability and impairment). The IBSEN data suggests that older people who use services (65 and over) would require a 25% increase in support for these age differences compared to younger people (aged 18 to 64) to be removed. The BHPS data more tentatively suggest that older people's access to services is slightly more limited than [that of] younger people […] The conclusion of the research that Jules Forder did was that, subject to a long list of caveats, the cost to public funds of eliminating age discrimination in adult social care by increasing the services for older people would be in the range of £2 to £3 billion per year […][190]

151. We heard dismaying evidence regarding what this apparent institutional bias against older people means in practice. The evidence of Andrew Harrop, Acting Charity Director at Age Concern and Help the Aged, was particularly striking:

There is a very good case going through the courts, the McDonald case, which demonstrates this, where a service user who was 64 was assessed for a package of around £700 per week including ILF [Independent Living Fund][191] support; for various administrative reasons, the application fell and was remade after her 65th birthday, she was turned down for Independent Living Fund, and then the council said, "We will not give you that package we assessed you for, we will not give you attendance at night, and instead we will make you wear incontinence pads all night rather than help you go to the toilet, even though you are not incontinent". That is a shocking example of age discrimination in practice. It really shows that it is also about assumptions, the outcomes people expect for different age groups are really different […][192]

152. Mr Harrop pointed out that resource allocations for Personal Budgets make this discrimination all the more transparent.[193] Ms Redmond, of Carers UK, similarly told us about:

a family where the husband was very severely disabled and his wife was doing most of his care [and] he was getting direct payments from his local authority. […] a letter arrived from the local authority saying, "Now your husband is an older person, his hourly rate will drop from £15 an hour to £12 an hour." That meant that she had to get rid of all those workers for the care package that she had set up, who of course were not going to work on a reduced rate, and so on.[194]

153. The issue of age discrimination is a powerful illustration that conventional ways of organising social care are often not focused on the needs of the individual service user. In this case, unwarranted assumptions are made about individuals' care and support needs essentially on the basis of the category of service-user into which they fall.

154. It is now illegal to discriminate on the grounds of race, gender, gender identity, disability, religion or belief, or sexual orientation in the provision of healthcare, medical treatment or social care. However, whilst it is unlawful to discriminate in employment on grounds of age, there is currently no statutory prohibition of age discrimination in providing health or social care.

155. The Government plans to address this anomaly by means of the Equality Bill, currently before Parliament. As part of preparing for the implementation of the Bill (which is intended to apply to health and social care by 2012), the DH commissioned a review of age discrimination in health and social care, which was published in October 2009.[195] The DH also commissioned the Centre for Policy on Ageing to do a UK literature review on age discrimination in social care, which was published in November 2009. A consultation about implementation of the Bill in health and social care is currently taking place.

156. We received written evidence from the Equality and Human Rights Commission assuring us that measures were being taken to address this issue without waiting for the Equality Bill to be passed.[196]

Conclusions

157. The multiple shortcomings of the existing social care system provide powerful arguments for fundamental reform. Too often when people approach the system for help they do not receive even information and advice on what is available and how to access it. The system is also often poorly co-ordinated with other help (not least NHS services and care provided voluntarily, as well as the housing support and social security benefits systems). People who need care and support encounter various forms of rationing, including by eligibility criteria, means-testing and charging, with much local variation. Where people are able to access care, it can be insufficiently focused on helping them to remain independent and avoid developing greater needs, as well as being limited in scope and not always of good quality. In these respects too, there is marked variation between local areas. The result is a social care system that:

— excludes many people with less severe care needs;

— penalises people with relatively modest financial means;

— places unfair and unreasonable demands on carers; and

— varies geographically to an extent that is strongly perceived as unfair.

In consequence of all these factors, there is a great deal of unmet need.

158. These shortcomings are all indicative of a system that: provides a residual or "safety net" service, rather than a universal one; is chronically underfunded; and is insufficiently focused on the needs and aspirations of the individual people who actually need care and support.

159. On the particular issue of quality, we note that the effectiveness of regulatory systems in uncovering and addressing poor quality care is an issue.

160. We have also concluded that more needs to be known about the role of particular factors in compromising standards. The staffing issues that we heard about (lack of training and career-development, inadequate staffing levels and high staff turnover), and their relationship to low pay levels, need to be investigated fully. The apparent quality "gradient" between for-profit and non-profit providers of care services is also of concern and this too needs to be fully examined.

161. Pervading the whole system of social care is a persistent ageism, both overt and covert. We welcome the fact that the Government and the Equality and Human Rights Commission have finally recognised this and begun to address it but we are appalled that this has taken so long.

162. The need for social care reform is clear. In the next chapter we look at how the Government has approached this and the reform programme that it has developed.

86 Ev 26 Back

87 Ev 56 Back

88 Ev 8 Back

89 Housing support services are provided by the authorities that also have social services responsibilities, except where there is two-tier local government, in which case responsibility rests with borough/district councils. Back

90 Health Committee, First Report of Session 1998-99, The Relationship between Health and Social Services, HC 74-I. The barriers identified were:

Lack of Clarity of Role and Responsibilities;

Financial Barriers;

Different Charging Policies;

Legal Barriers;

Different Priorities;

Lack of Coterminosity (of administrative boundaries);

Different Cultures; and