Conclusions and recommendations
1. Adult social care is personal care and practical
support for adults with physical disabilities, learning disabilities,
or physical or mental illnesses, together with support for their
carers. The Government's objectives are to enhance people's quality
of life, delay and reduce the need for care, ensure positive care
experiences and safeguard adults from harm. In 2012-13, local
authorities provided or commissioned £19 billion worth of
individual packages of care and universal care services. In addition,
the NHS spent an estimated £2.8 billion in 2011-12 on social
care, while the Department for Work and Pensions' spending on
incapacity, disability and injury benefits totalled £28.2
billion in 2012-13. However, publicly funded care makes up only
a minority of the total value of care, and this proportion is
decreasing. Most care is provided informally by unpaid family,
friends and neighbours. In 2012, the Department of Health announced
new legislation, the Care Bill,[1]
designed to rationalise local authorities' obligations and to
introduce new duties based on individual wellbeing.
The need for collaboration across all bodies and
at all levels
2. Successful implementation of the Care Act
depends on an unprecedented amount of collaboration at every level
of government. How well care services meet adults' needs depends
on all parts of the complex system of related public services
and forms of support working together.
We were pleased to hear of strong joint
working between the Department of Health and the Department for
Communities and Local Government. But effective joint working
is not yet extended to other departments, most notably the Department
for Work and Pensions which spends £28.2 billion on incapacity,
disability and injury benefits and is reforming the welfare system.
For example 2.2 million people have given up work to care, adding
costs to the benefits bill and loss of tax revenues to the Government.
In introducing Personal Independence Payment, the Department for
Work and Pensions expects 600,000 fewer disabled people to receive
support towards the additional costs of living with a disability
than under Disability Living Allowance. Collaboration is also
essential at the local level. Local authorities are sharing and
learning from evidence on the ground but sector-led improvement
is in its infancy. Costs vary enormously with for example the
costs for domiciliary care ranging from £10 per hour to above
£20 per hour. We are concerned that the plan to make GPs
formally accountable as lead professionals, responsible for coordinating
an older person's care across multiple professions, will not work
in practice. We
welcome the Departments' determination to keep a central grip
on matters and their recognition of responsibility for the system
as a whole. There are clear tensions between the commitment to
localisation and the determination to achieve best value across
all areas.
Recommendations:
The Department of Health and the Department
for Communities and Local Government should expand their effective
cooperation to include all relevant government departments, in
particular the Department for Work and Pensions.
The Departments should set out how they intend
to support local authorities, the organisations that represent
authorities and the wider adult care sector, including providers
and voluntary organisations, to collaborate, share and learn from
good practice. They should consider whether and what action they
will need to take if efforts to spread best practice are not effective.
The need to understand how the system can cope
with increasing demand and at the same time implement ambitious
changes
3. The Departments do not know whether the
care system can become more efficient and spend less while continuing
to absorb the increasing need for care. Need for social care
is continually increasing because the people who need it, mostly
older and disabled people, are two groups in society that are
growing in size. Yet public funding to support these groups is
falling with an 8% real terms cut in spending between 2010/11
and 2012/13. This has led local authorities to focus on severe
need and reduce its spending on preventative care and support
to adults. Local authorities' cost savings have been achieved
by paying lower fees to providers, which has led to very low pay
for the care workforce, low skill levels within the workforce,
and inevitably poorer levels of service to users. We are concerned
to learn that up to 220,000 people working in the care system
earn less than the minimum wage. We also learnt that in some localities
whilst local authorities might pay private providers £13
an hour, the worker would only earn minimum wage of around £6
per hour. We are concerned that the Departments have not fully
addressed the long-term sustainability of the adult social care
system and that its policies to drive change (the Care Act and
the Better Care Fund) are risky, are not supported with new money,
and do not acknowledge the scale of the problem. In 2012-13, local
authorities spent between £350 and £640 a year on adult
social care services for each person in the local authority area.
The Departments believe that the wide variations in costs between
local authorities indicate that many can meet financial pressures
through local efficiency initiatives and transforming services—but
the NAO report concludes that much of this cost variation is not
due to inefficiencies but can be explained by social, economic
and demographic factors, many of which are either outside a local
authority's control or can only be influenced long term. The Departments
acknowledge that they do not know how local authorities will achieve
the required efficiencies, but still believe the ambitious objectives
of implementing the Care Act and integrating services are achievable.
Meanwhile, families are caring for relatives more and more, leading
to over 2 million giving up work to care at extra cost to the
Government through the benefits bill, and almost all seeing no
prospect of their quality of life improving.
4. The Departments do not have the information
and evidence to understand fully the challenges that local authorities
face in commissioning and providing adult social care and supporting
carers. The Care Act will introduce new duties on local authorities,
including a duty to assess carers' needs and provide support and
obligations in respect of those that fund their own care (self-funders).
These new duties are being introduced as local authority budgets
become increasingly constrained with many local authorities already
cutting their social care budgets. The Departments neither understand
the scale of some of these challenges nor how much it will cost
to implement the changes the Care Act will introduce. The Department
of Health acknowledges that it does not know whether some preventative
services and lower level interventions are making a difference.
We welcome its acceptance that more research is needed to identify
the most effective ways of working. Local authorities have little
information on the numbers, needs, spending and outcomes of self-funders
in their areas, nor the numbers of carers. There are concerns
that funders are being charged more to subsidise the publicly
funded places. Similarly, there are limited data on how people
spend direct payments and the quality of care bought. This makes
it difficult for authorities to understand, let alone manage,
their local care markets. The Departments acknowledge that there
is not yet sufficient transparency over data to enable local authorities
to see where their costs are high compared to others.
5. It may not be feasible for local authorities
to implement all the proposed changes to the intended timetable.
The Care Act will bring significant changes for local authorities
and the Departments accept that the changes present a formidable
challenge. The Departments expect to see measurable progress from
April 2015 but the timetable is very tight. The Association of
Directors of Adult Social Care, representing local authorities
is sceptical about whether the changes can be implemented by local
authorities, in the timescales expected by the Departments. The
Better Care Fund aims to enable innovation and accelerate efficiencies,
for example, through integration of care and health services,
but planning for its introduction has been slower than expected
and evidence shows integration takes time.
Recommendations:
The Departments should quantify the new burdens
the Care Act will introduce for local authorities, establish a
realistic timetable given the financial constraints, and acknowledge
the limits on the sector's capacity to absorb the growing need
for care with falling public funding. To achieve this they must:
· address
gaps in evidence, information and evaluation in relation in particular
to the effectiveness of preventative services, the needs of and
quality of care to self-funders, and spending by direct payment
recipients.
· take
account of the impact that local authorities driving down providers'
fees is having on service quality, the charges to those who fund
themselves and use the same care services, and the financial sustainability
of providers.
· assess
the nature, extent, impact and implications of the growing burden
on informal carers and the extra cost they place on benefits paid
out by the DWP .
· assess
the scope for local authorities to make further efficiency savings,
taking account of both best practice benchmarking of costs and
of wider social, economic and demographic trends over which local
authorities have little control.
· Determine
ways to ensure the local authorities do learn from best practice
and achieve best value.
The Departments should define what progress
is expected under the Act by when, how they will measure progress
and how they will judge success. For example, to work with greater
numbers of self-funders than they have historically, local authorities
will need to understand their number and what needs they have,
and set up new systems. The Departments should monitor local authorities'
progress and make their expectations clear on what should be achieved
in what timescale.
The need for oversight arrangements to reflect
the overriding importance of quality of care
There are continuing risks to quality of care and
continuity of services both because of pressures on providers
and changing oversight arrangements. We are astonished that up
to 220,000 care workers earn less than minimum wage and seemingly
little has been done to rectify this, and that around one third
are on zero-hours contracts. Around half of local authority directors
of adult social care report that cost-saving is putting pressure
on the financial sustainability of some private sector providers.
The Departments do not know the extent of cross-subsidisation
between self-funders and local authority funded users. The Department
of Health currently monitors the financial sustainability of the
top five providers. From
April 2015 the Care Quality Commission will monitor the top 40
or 50 providers and if necessary take action to ensure continuity
of care for users. The Commission, which has recently been overhauled,
currently lacks the skills to undertake this expanded level of
monitoring but the Department of Health is confident the necessary
skills will be in place by April 2015.
Recommendation: The
Department of Health needs to be assured that the Care Quality
Commission is adequately prepared and staffed to monitor both
the quality of services and the sustainability of providers under
the new oversight regime.
6. Local authorities, who have a duty to safeguard
vulnerable adults from abuse and harm, have seen a recent rise
in safeguarding referrals. Local authorities have a duty to work
with the police, local NHS bodies and other partners to safeguard
vulnerable adults from abuse and neglect. Safeguarding referrals
recorded by local authorities have risen 13% in the two years
since 2011. This
increase may reflect increased awareness of abuse or may reflect
overstretched resources and pressure within the system. Far too
many referrals, 43%, have been substantiated. There has been a
tenfold increase in calls to the Care Quality Commission's whistleblowing
helpline and we welcome the creation, under the Care Act, of statutory
safeguarding boards.
Recommendation: The
Department of Health, in conjunction with local authorities, needs
to understand why safeguarding referrals are rising, in particular
whether this indicates rising levels of abuse, and target its
interventions and support to local authorities accordingly.
1 The Care Act received Royal Assent on 14 May 2014 Back
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