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:
of information and advice;
lack of joined-up care;
limitations and variations in access
unfairness of means-testing and charging;
significant demands on carers;
lack of focus on prevention, rehabilitation
high levels of unmet need;
variations in quality of care;
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 millionor £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.
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.
Similarly, we heard from Mencap, the learning disability
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.
Lack of joined-up care
82. The social care system has a complex and
difficult interface with other forms of state care and support:
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
(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
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;
some of these problems have been mitigated but none of them has
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
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".
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".
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.
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.
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.
The report expressed concern that FACS was being used crudely
to curb demand, with damaging consequences for vulnerable people.
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.
(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".)
87. The CSCI review identified multiple problems
with the current system of eligibility including:
of clarity and transparency;
service-led rather than needs-led approaches;
limitations of a risk/needs based model;
insularity and fragmentation;
marginalisation of prevention and inclusion
inadequate approaches to diversion 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.
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.
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.
Unfairness of means-testing and
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.
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.
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.
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".
Since then, prices have fallen; but the average price in the third
quarter of 2009 still stood at £197,277.
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.
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).
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),
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
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.
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,
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
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.
99. In addition to user charges, people can experience
pressure to pay top-ups (paid in addition to local authority standard
rates) 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
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 servicethe
same food, the same servicethey 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.
101. Charging for non-residential care, where
councils have considerable discretion, also shows great local
variation and can effectively operate as a further "postcode
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.
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".
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
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
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.
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.
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.
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.
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.
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 [
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.
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
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
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
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
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.
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.
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.
As such, the system can aptly be characterised as
"penny-wise and pound-foolish".
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
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".
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. 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".
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
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.
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
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.
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".
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".
These figures have been calculated for the DH by the PSSRU.
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
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.
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.
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
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";
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".
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."
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.
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.
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.
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
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
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 respectincluding
improving arrangements for safeguarding people [i.e. protecting
vulnerable adults from potential abuse].
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
There are now no poor councils for the first time
ever 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
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.'"
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 [
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
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.
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".
133. When we asked Baroness Young about the danger
of regulation being merely a "tick box" exercise, she
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 aboutthe outcomes, whether they are treated
with dignity and respect, whether their rights are respected,
as well as a whole variety of other issuesand 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)
coming into force on 1 October 2010 for adult social care providers.
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
POSSIBLE REASONS FOR POOR QUALITY
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.
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.
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".
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. 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".
140. Average gross expenditure per hour on homecare
in 2007-08 was £14.45; again, there were significant variations
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.
141. The Association identified as a particular
problem the use of "e-tendering",
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
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
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".
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
143. Baroness Young told us there was evidence
that "major cost reduction programmes" were associated
with lapses in quality.
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.
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.
Representatives of the larger providers insisted that very high
headline figures were too easily misunderstood because of the
complexity of the businesses concerned.
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
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".
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.
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.
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.
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.
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. At the
root of this seem to be extremely low levels of pay, allied with
very low status,
meaning that to be a care home worker one must be either "altruistic
Data from Skills for Care
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.
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,
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
A recent Oxfam report claimed that migrant workers were being
exploited by some care homes, with employers often paying less
than the minimum wage;
this was, however, denied by the care home owners' representatives
who gave evidence to us.
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 [
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]
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 [
152. Mr Harrop pointed out that resource allocations
for Personal Budgets make this discrimination all the more transparent.
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.
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.
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.
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:
many people with less severe care needs;
penalises people with
relatively modest financial means;
unfair and unreasonable demands
on carers; and
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
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
Ev 56 Back
Ev 8 Back
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
Health Committee, First Report of Session 1998-99, The Relationship
between Health and Social Services, HC 74-I. The barriers
- Lack of Clarity of Role and Responsibilities;
- Financial Barriers;
- Different Charging Policies;
- Legal Barriers;
- Different Priorities;
- Lack of Coterminosity (of administrative
- Different Cultures; and
- Differences in Democratic Accountability.
Cf. Health Committee, First Report of
Session 1995-96, Long-Term Care: NHS Responsibilities for Meeting
Continuing Healthcare Needs, HC 19-I; Health Committee, Sixth
Report of Session 2004-2005, NHS Continuing Care, HC 399-I. Back
Ev 60 Back
Ev 111 Back
Ev 31 Back
Ev 75 Back
Commission for Social Care Inspection, The State of Social
Care in England 2006-07, January 2008 Back
Melanie Henwood and Bob Hudson, "Lost to the System? The
impact of Fair Access to Care: A report commissioned by the Commission
for Social Care Inspection for the production of The State
of Social Care in England 2006-07", January 2008 Back
This figure is derived from CSCI Self-Assessment Survey returns
from local authorities. Back
Q 877 Back
Ev 9, 11; Q 15 Back
Ev 129. This issue was acknowledged by CSCI in its review of eligibility
Ev 55 Back
Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, pp 97-98; cf. Q 22 Back
Ev 98 Back
Graeme Chamberlin, "The housing market and household balance
sheets", Economic & Labour Market Review, Vol
3 (2009), p 24 Back
Department for Communities and Local Government Live Tables, Table
508 Housing market: mix-adjusted house prices, by new/other dwellings,
type of buyer and region, United Kingdom, from Quarter 2 1992 Back
"How will you pay for your long-term care?", Sunday
Times, 7 February 2010 Back
Q 290 Back
Councils currently have the discretion, under section 55 of the
Health and Social Care Act 2001, to offer a person who fails the
means test on account of property assets a Deferred Payments Agreement
after the end of the 12-week disregard period. Where this is approved,
the council continues to pay for care, effectively providing an
interest-free loan that is repaid from the proceeds when the property
is eventually sold (following termination of the agreement by
the resident or after their death). The council can begin charging
interest on the loan 56 days after the resident's death. Back
Q 4 Back
The dissenting members of the Royal Commission on Long-Term Care
argued, in support of means-testing, that "The alleged fecklessness
of those who benefit under the existing system is largely urban
myth. Most people are not old and poor because they have been
feckless. Most people are old and poor because before that they
were young and poor - low earners, unemployed, single parents,
unable, even if they were willing, to save enough for their own
old age" (Royal Commission on Long-Term Care, With Respect
to Old Age, 1999, Note of Dissent, para 50). Back
HC (2009-10) 269-i, Table 38c Back
Where a local authority is providing funding towards care home
fees, any top-up may only be paid by a "third party";
it cannot be paid by the person receiving local authority funding.
It is estimated that 28% of local authority funded residents were
in receipt of third-party top-ups in 2009 (Laing & Buisson,
Care of Elderly People: UK Market Survey 2009, p 178). Back
Ev 135; cf. Q 594 Back
Coalition on Charging, Charging into Poverty?: Charges for
care services at home and the national debate on adult care reform
in England (2008) Back
HC (2009-10) 269-i, Table 38b Back
Ev 64-65 Back
Ev 63 Back
Ev 33, 103, 144 Back
Q 174. It should be noted that people receiving care and support
from carers who are not receiving formal care will not always
have applied for formal care. Some may not have done so, either
because they do not feel the need for formal care or because they
have no expectation of getting it. Also, it should be remembered
that living alone is here being used as a proxy for not receiving
informal care; it may be that some people living alone still receive
informal of one kind or another (e.g. from friends or neighbours). Back
Q 177 Back
This estimate, based on work done by researchers at the University
of Leeds, was published in Carers UK, Valuing Carers - calculating
the value of unpaid care (London, 2007). The UK figure is
£87.0 billion. Cf. Q 747. Back
Age Concern and Help the Aged, Big Questions for the future
of care: Our ten tests for the Government's Green Paper on the
future of care and support (London, 2009), p 14 Back
The benefits system provides some support to carers, in the form
of the Carers Allowance, but this is very limited in scope (Work
and Pensions Committee, Fourth Report of Session 2007-08, Valuing
and Supporting Carers, HC 485-I). Back
Q 229 Back
Q 748 Back
Q 232 Back
Qq 131-132, 617, 721 Back
Q 684 Back
SC 9 (BP) Back
Q 51. CSCI found that "Councils do not monitor what happens
to people signposted to other support, so unmet need is not being
recorded nor are those people's outcomes known" (Commission
for Social Care Inspection, Cutting the Cake Fairly: CSCI review
of eligibility criteria for social care, October 2008, para
Ev 117 Back
Q 882 Back
Q 41; cf. Q 595 Back
Commission for Social Care Inspection, The State of Social
Care in England 2006-07, January 2008, p 109 Back
Q 41 Back
Qq 880, 882 Back
Julien Forder and José-Luis Fernández, Analysing
the costs and benefits of social care funding arrangements in
England: technical report, Personal Social Services Research
Unit Discussion Paper 2644, July 2009, Table 25, p 39 Back
Q 686 Back
Q 705. Cf. Qq 598, 702, 721, 767; Ev 35, 54, 82 Back
Qq 357, 360, 380, 408, 415, 498, 513, 598; Ev 51, 52, 53, 82,
83, 109 Back
Ev 32 Back
Q 598 Back
Coalition on Charging, Charging into Poverty?: Charges for
care services at home and the national debate on adult care reform
in England (2008) Back
Q 598 Back
Recent examples include the television series "Can Gerry
Robinson Fix Dementia Care Homes?" (broadcast on BBC2 on
8 and 15 December 2009) and the book Beyond the Façade
(Brentwood, 2008), by the whistleblower Eileen Chubb, of the group
"Compassion in Care" (www.compassionincare.com). Back
Professor Sube Banerjee, "The use of antipsychotic medication
for people with dementia: Time for action - A report for the Minister
of State for Care Services", November 2009; "'Chemical
cosh' drugs 'killing thousands a year'", Daily Telegraph,
13 November 2009; Royal College of Physicians /British Society
of Gastroenterology, "Oral feeding difficulties and dilemmas:
A guide to practical care, particularly towards the end of life",
January 2010; "Care homes forcing elderly to have feeding
tubes fitted", Guardian, 6 January 2010 Back
The seven outcomes are:
- Improving health & well-being;
- Improved quality of life;
- Making a positive contribution;
- Increasing choice & control;
- Freedom from discrimination and
- Achieving economic well-being; and
- Maintaining dignity & respect. Back
Care Quality Commission, Performance judgements for adult social
services An overview of the performance of councils in England,
December 2009, p 1. Two councils were rated "Poor" on
Outcome 7, "Maintaining dignity & respect". Back
"Thousands condemned to live in squalid care homes",
The Times, 3 December 2009; "Nearly 4,000 adult social
services criticised over level of care provided", Guardian,
3 December 2009; "Care for 80,000 elderly not up to standard",
Daily Telegraph, 3 December 2009; "Adult social care
warning for eight areas of England", BBC News Online,
3 December 2009, news.bbc.co.uk Back
In fact, no council has ever been rated "Poor" on "Delivering
outcomes" (under the 2007, 2008 and 2009 ratings system)
or "No" on "Serving people" (the equivalent
in the 2005 and 2006 ratings system). Back
Q 837 Back
Q 836 Back
Q 306 Back
Regulation does not apply to services purchased from PAs, family
members or friends using Direct Payments, even if those services
include personal care. Day care settings that provide personal
care are also unregulated. Back
Q 303. The number of adult social care services rated "poor"
totals 426 (1.7%) and those rated "adequate" total 4,073
(16.7%) (Care Quality Commission, The state of health care
and adult social care in England: Key themes and quality of services
in 2009, HC (2009-10) 343, p 74). Back
Q 837 Back
Fear that many care homes would be driven out of business by the
environmental standards for care homes led the Government to downgrade
this aspect of the NMS to the status of "aspirational"
only in 2003. According to the leading analysts of the care home
industry: "This about-turn in government policy [
has held back modernisation of the care home sector by in effect
giving many physically sub-standard care homes a licence to operate
indefinitely" (Laing & Buisson, Care of Elderly People:
UK Market Survey 2009, p 43). Back
Services purchased from PAs, family members or friends using Direct
Payments will continue to be unregulated under the new system,
as will day care settings that provide personal care. Shared lives
services (adult placements) that do not involve personal care
will not need to be registered under the new system, although
they are currently regulated. Back
Q 837 Back
Q 306 Back
HC (2009-10) 269-i, Tables 35a, 35b, 35c, 35d Back
Q 581 Back
HC (2009-10) 269-i, Tables 35a, 35e Back
Q 439 Back
"E-tendering" is the use of automated, online systems
for the process of advertising contracts, gathering bids and awarding
contracts. It is intended to make the process of tendering faster,
easier and less costly. Back
Ev 51 Back
Q 519 Back
Ev 35 Back
Ev 110 Back
Q 306 Back
Ev 135; Qq 121-123, 187, 446, 472, 477, 481, 594 Back
This is calculated on an EBITDAR (Earnings Before Interest, Taxes,
Depreciation, Amortization and Rent) basis (Laing & Buisson,
Care of Elderly People: UK Market Survey 2009, p 212).
We were told that a return on revenue in the "high 20s"
was "more or less" equivalent to a return on capital
of 12%. Back
Q 532 Back
Q 587 Back
Q 531 Back
Ev 82 Back
Q 316 Back
Q 317 Back
Vikram Comondore et al., "Quality of care in for-profit
and not-for-profit nursing homes: systematic review and meta-analysis",
British Medical Journal, vol 339 (2009), b2732 Back
Q 306 Back
Qq 317, 770 Back
Q 476. This comment was made by Lord Sutherland at a meeting in
the Palace of Westminster on 18 November 2009 ("Shaping the
Future of Care Together - Green Paper ... making the vision a
reality"), organised by Public Policy Projects. Back
Skills for Care is part of Skills for Care and Development, the
sector skills council for social care, children, early years and
young people's workforces in the UK. Skills for Care aims to improve
adult social care services across the whole of England by supporting
employers' workforce development activity. Back
Skills for Care, National Minimum Data Set - Social Care briefing
no. 8 (Pay), April 2009; cf. Ev 52; Qq 445, 473-474 Back
Ev 82 Back
SC 54 Back
Oxfam, Who cares?: How best to protect UK care workers employed
through agencies and gangmasters from exploitation, December
2009; "Unfair demands", Guardian, 2 December
Q 449-450 Back
Q 209. The published study is Julien Forder, The Costs of Addressing
Age Discrimination in Social Care, Personal Social Services
Research Unit Discussion Paper 2538, April 2008. Back
ILF is a form of benefit paid by the DWP to help disabled people
under the age of 65 to live more independently. Back
Q 603 Back
Cf. Q 783 Back
Q 714 Back
Q 914; Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, p 35 Back
SC 61 Back