6.In the report we published before the Spring Budget, we examined the reasons for the funding pressures on the adult social care system and looked at how councils had coped with those pressures by redesigning services and making other efficiency savings. We came to the conclusion that the Chancellor should provide immediate additional funding for social care and commit to closing the funding gap for the rest of the Parliament. In this chapter, we bring together evidence to show the very serious consequences that constrained social care funding has had on: the quantity and quality of the care people receive; the NHS; care providers; the care market and care commissioning; the workforce and carers.
7.The social care sector is affected by the demographic pressure of a growing and ageing population with increasingly complex care needs. According to the National Audit Office (NAO), while the overall adult population grew by 10% between 2001 and 2011, the number of people aged over 65 grew by 11% and the number aged over 85 grew by 24%. As adults are living longer, their care needs are increasing and, in addition, more people with disabilities and complex health conditions are living longer.
8.Where a local authority has assessed a person as having needs for care and support, the Care Act 2014 requires that it must meet those needs. However, the evidence we received, which we examine below, suggested that an increasing proportion of people with care and support needs were getting no care at all (unmet need) and that those who did receive care were not getting enough (undermet need). The service users and unpaid carers who took part in our roundtable said that funding pressures on councils were visible in the form of service reductions, including closures of day care centres, and were resulting in increased reliance on families and carers.
9.As a result of changes in councils’ data reporting requirements, it is not possible to compare how the numbers of people receiving care have changed year-on-year over recent years. However, we know that the number of people receiving care from local authorities fell by 25% (427,000) between 2009–10 and 2013–14 and that there was a further fall of 2% (19,000) between 2014–15 and 2015–16.
Figure 1: Number of people receiving local authority funded social care, 2009–10 to 2013–14
Age UK said that the number of older people receiving social care had fallen from 1.2 million in 2005–6 to 850,000 in 2013–14, despite the rising numbers of older people in the population. This is confirmed by what we heard from councils. Jon Rouse, Chief Officer of Greater Manchester Health and Social Care Partnership, said that, over the last seven years, there had been a “20%-plus reduction in the number of people in residential and nursing care in Greater Manchester, and a 25% reduction in the number receiving domiciliary care”, and Newcastle City Council and the London Borough of Havering also said they had reduced the number of people to whom they were providing care.
10.From April 2015, a national minimum threshold for eligibility for care was introduced. This means that councils are required to provide care and support for people whose needs have a “significant impact on their wellbeing”. Our witnesses from Newcastle and Haringey councils said their organisations had reduced the number of people they cared for not only by promoting independence and being flexible with support but also by “strict adherence to the eligibility criteria”. José-Luis Fernández, Deputy Director of the Personal Social Services Research Unit at the London School of Economics and Political Science (LSE), observed that the “system’s concentration on people with very high needs is associated with a significant drop in the resources available”. One of the carers who attended our roundtable said that, while supervising her mother’s care, she had witnessed how funding was driving decision-making about eligibility for care and that this was forcing people out of the system.
11.Age UK said that levels of “under-met” need were rising and that, in 2015:
The number of older people who had difficulty undertaking activities of daily living (such as getting dressed, washed and eating) and instrumental activities of daily living (including managing medication, cooking or shopping for essential items) and who did not receive adequate help exceeded one million for the first time.
The organisation has since updated this figure to 1.2 million. Vicky McDermott, Chair of the Care and Support Alliance, said that her organisation was in contact with people who had been affected, including an older person who was sleeping in their wheelchair having had their home visits reduced to one a day. We heard similar accounts from other people who received council-funded social care. A contributor to our online forum said:
Having disabilities, I am already at a disadvantage in general, but requiring the equipment and support I do daily from the moment I wake up til the moment I go to bed every day and at night means what I require is expensive. I realise there are cutbacks, but being told during numerous assessments throughout my life that there is “no money” for what I require is deeply worrying and demoralising.
Another contributor to the forum said:
Currently I pay my self-employed, tax paying etc carer/personal assistants (PA) the sum of £10 per hour. My local council has just undertaken my annual review, cut my hours by 10% and reduced the hourly rate to £7.35 per hour this is worrying. I need 2 people to take me out, been outside 4 times this year so far. My PAs have now said they will be leaving in September, they cannot afford to work.
We also heard that care was not being increased at the rate that people’s needs were growing. One witness, Anna Severwright, told us that, although her hours had been increased at her last review, she felt that the deterioration in her condition meant that she should have had a bigger increase.
12.We were therefore not surprised to hear witnesses say that they felt that the care they received did not promote their wellbeing as required by the Care Act 2014. Larry Gardiner said that his care package was “simply written to keep me hydrated—fed and watered—and hygienic” and other people we spoke to said the system had become focused on “functionality”, or washing and dressing, with no regard to combatting isolation and loneliness. Scope said that their 2015 research into the experiences of 500 working-aged disabled people had shown that more people were receiving the “basics of care” and fewer people were receiving support to meet their “wider needs and aspirations”, such as employment, education and training. Anna Severwright said that her main worry was not about her quality of life but what was going to happen to her care in the future.
13.The Health Minister, David Mowat, told us that councils were fulfilling their duties under the Care Act and that Age UK’s figures related to “services that were previously non-statutory and may have been withdrawn […] things like meals on wheels”. Age UK has however since written to the Committee to explain that their figures were based on statutory services and reflected the number of people they have estimated to have a need for social care which is not being met. Sector organisations have also warned that councils are facing difficulties in meeting their statutory duties. The Association of Directors of Adult Social Care (ADASS) said that only 8% of Directors were fully confident of being able to deliver all of their statutory duties this year, 2017–18. The Local Government Association has said that reductions in care will “constitute a failure to meet both the spirit of the Care Act and its statutory duties” and that, as a result, councils are likely to face an increase in judicial reviews.
14.Councils are coping with reduced budgets by providing care and support to fewer people and concentrating it on those with the highest needs. They are also reducing care provided to the minimum required for a person to get through the day, and are not promoting wellbeing nor increasing care in accordance with need. Many councils are therefore potentially in the position of being unable to comply with their Care Act duties and may therefore face legal challenges. It is alarming that fewer than one in twelve Directors of Adult Social Care are confident that their local authority will be able to meet its statutory duties in 2017–18.
15.José-Luis Fernández of the LSE said, however, that it should not be assumed that, because councils were providing less care, people’s needs were going unmet: “you become a self-payer, or you get some unpaid care, or you go without”. He added that “it was very difficult to find those people with social care needs outside of the system”. Councils are, however, required to consider how to identify unmet need in their area but, according to ADASS, only 34% have monitoring arrangements in place. The evidence we received indicated that unpaid carers were having to step in to meet shortfalls in the care provided by councils; for example, Isaac Samuels told us that he had mitigated the shortfall in the care the council provided with unpaid care from friends and family. We also heard evidence that reductions in services were placing pressure on hospitals through rising emergency admissions and delayed transfers of care. We explore these issues later on in this report at paragraphs 28 to 41.
16.Little is known about what happens to people who are not receiving any or enough care, and whether they are paying themselves, relying on carers or coping alone. Data on delayed transfers of care and emergency admissions suggest that unmet need is placing significant pressure on the NHS. We are disappointed that so few councils have monitoring arrangements in place to identify unmet need. Without such arrangements, it will be impossible to understand the scale of unmet need. We therefore urge all councils to consider how to identify unmet need and to put arrangements in place for this. This will help to build up a national picture of unmet need and inform overall funding decisions.
It has to look at people’s satisfaction and the happiness that people have in services; it has to have some minimum standards about the kind of services, how frequent, reliable and regular services are, and the skills of the people involved; it has to set standards around the quality of the work people are actually doing. It has to have a combination of those and a focus on outcomes.
We believe that it has been possible to build up an overall picture of quality by looking at inspection results and other indicators, alongside the evidence we heard from people who receive social care, councils and care providers. We explore how care commissioning and the workforce affect quality in later sections of this report.
18.The Care Quality Commission (CQC), the care regulator, published its assessment of the state of care in England in 2015–16 in October 2016. This is the second of such reports, following the introduction of a new ratings system in 2014. The CQC found that in 2015–16 “despite some variation, overall quality remains good”, with 1% of adult social care services rated outstanding, 71% good, 26% ‘requires improvement’ and 2% inadequate. While these results are an improvement on 2014–15 when the CQC rated 1% of services outstanding, 59% good, 33% ‘requires improvement’ and 7% inadequate, we note that more than a quarter of care services (28%) are rated as requiring improvement or inadequate.
19.According to the CQC, there was variation in terms of service type; they found that nursing homes were the “biggest concern”, with 1% rated outstanding, 58% good, 37% ‘requires improvement’ and 4% inadequate. Sir David Behan, the Chief Executive of the Care Quality Commission, said that the workforce was key to this:
The people in nursing homes are very old and both physically and intellectually frail, and therefore the levels of skill and numbers of people required to make sure that they are clean, hydrated and fed is a key issue. If you look at what we reflect in our reports, very often in care and nursing homes for the very elderly, it will be about the adequacy of staff and their care.
Furthermore, the CQC found that smaller nursing and residential homes performed better overall: they believed this was because caring for small numbers of people made it easier to respond to people’s needs and deliver person-centred care. Extra-large home care agencies (250 plus staff) performed the worst, with 7% rated inadequate.
20.The Director of Resources at Newcastle City Council, Tony Kirkham, said he thought the quality of their services was still good and Cllr Noble, the Spokesman for Health and Social Care at the County Councils Network, said he did not accept that councils were commissioning care of lower quality because there was less money in the system. However, Cllr Arthur, Cabinet Member for Finance and Health at the London Borough of Haringey, did think that quality of provision had reduced and a group of councils in the East of England said that there were signs that financial and recruitment pressures were affecting the quality of care:
In Essex, a consistent number of providers cause ongoing concern and there have been significant service failures in the past 18 months. 14 provider contracts for care services have been terminated since November 2014 due to poor quality. Norfolk has seen a reduction in the overall quality of care, with less residential care providers (59.6%) achieving Good CQC inspection ratings compared to the average for England (68.1%).
Furthermore, the Association of Directors of Adult Social Care said that 82% of Directors of Adult Social Care had reported that more providers already faced quality challenges as a result of the savings being made to social care budgets.
21.The providers we heard from were concerned about maintaining quality in the face of pressure from councils to reduce fees. For example, Humberside Independent Care Association said that “the practice of always choosing the cheapest provider forces quality down”. Some providers said they preferred to provide no care at all than poor quality care at reduced fee levels. Mandy Abbey, who runs a care agency, told us she was “being put under enormous pressure to cut care to the point where quality of care and quality of lives are hugely impacted on”, which she refused to do. This was also the case for much larger providers, like Four Seasons Healthcare. Providers were, however, doing whatever they could to continue providing quality care, often to the detriment of their business. Andrew Dykes, the Chairman of Exalon Autonomy Group, a care provider for adults with learning disabilities, said that they had kept the quality of care up by “extend[ing] bank terms and reduc[ing] management overheads as far as possible” and by being fortunate in having low staff turnover.
22.An important indicator of quality is how satisfied care users are with the services they receive. According to the Personal Social Services Adult Social Care Survey, only 3.6% of people in England were dissatisfied with their publicly-funded care in 2015–16. Richard Humphries of The King’s Fund pointed out the limitations of such surveys: “there is a danger, particularly with older people, that gratitude and relief is not necessary the same as satisfaction”.
23.The Personal Social Services Adult Social Care Survey results contrast with the rising number of complaints to the Local Government Ombudsman (LGO) about adult social care. Since 2014–15, the number of complaints received about independent providers has increased by 19% and the number of complaints and enquiries about care arranged privately with independent providers increased by 21%. Most complaints were about residential and home care, of which 58% and 65% respectively were upheld after a detailed investigation. We note that the LGO and the CQC work together closely, sharing information received through complaints to inform regulatory action.
24.The Channel 4 Dispatches documentary, Britain’s Pensioner Care Scandal, gave us an insight into what poor care looks like and its repercussions. Through secret filming and undercover reporting, the programme highlighted serious concerns about the standard of home care provided to older people in Haringey. Ray James, whose mother’s care was filmed, told us about the impact that poor care had had on his mother’s physical and mental health and the distress that this had caused to both of them. The Relatives and Residents Association, whose evidence was based on what the relatives of people receiving care had told them, said that the quality of service had been adversely affected by cuts to social care budgets. Carers also had concerns about quality; for example, Independent Age said that some were having to refuse respite care because of this and that those who did accept it felt “unease and worry that [it] would not be adequate”.
25.The evidence from the three witnesses who receive social care suggested that the way the system was set up affected the quality of their care overall. Isaac Samuels said that the care he received was not joined up and that, as a result, the burden of coordinating it fell to him. Larry Gardiner described the difficulties he had had in moving from one local authority area to another and having to be reassessed for care. Asked whether she had choice and control over her care, Anna Severwright said:
There are choices, as long as it fits within the system or within their boxes. I feel like my life is a unique journey that doesn’t fit into any boxes, and nobody else has ever done it before, so my care needs to be truly unique. I would like it to be that somebody comes out and says, “So what is your life about?” and then, “How do we fit the care to that?” and not, “Okay, this is what we do.” Often—usually—they are used to working with more elderly people.
We also heard about the difficulties witnesses had had with securing funding for home adaptations through the Disabled Facilities Grant and explore this issue in paragraphs 122 to 124.
26.The CQC’s 2015–16 report concluded that, although adult social care services have been able to maintain quality, sustainability was a concern. They cited the facts that a quarter of services did not improve after receiving an inadequate rating last year, that half of services rated as ‘requires improvement’ which were re-inspected had not improved and that, in 8% of cases, care had become inadequate. The concerns providers expressed about maintaining quality (discussed at paragraph 21) echo the CQC’s findings, as did 95% of Directors of Adult Social Care responding to ADASS’ Budget Survey 2016 who thought that more providers will face quality challenges in the future.
27.The number of complaints about social care to the Local Government Ombudsman is high, and rising, and the Care Quality Commission found that, in 2015–16, 28% of care homes required improvement or were inadequate, with some types of services, such as nursing homes, significantly worse rated. Councils are becoming concerned about quality of care, and care providers, and the Care Quality Commission are concerned about its sustainability. We share their concerns and fear that overall quality of care is likely to continue to deteriorate, unless sufficient funding is provided.
The most obvious measure of stress in the system is the number of older people who are stuck in hospital when they, their families and their nurses and doctors know it would be better for them to be looked after back at home or, indeed, in an appropriately high-quality care home.
Stephen Dorrell, Chair of the NHS Confederation, added that there was also pressure from “the people who present at the front door of the hospital, as a result of failure to deliver home care services [which] have been particularly hard hit by […] social care funding”. These are known as ‘emergency admissions’.
29.According to NHS Guidance, a delayed transfer of care occurs when a patient has been deemed ready to depart from acute or non-acute care and is still occupying a bed. The number of delayed transfers of care are recorded at the end of each month, alongside the reason for the delay and whether the delay was attributable to the NHS, the local authority or to both organisations. The reasons are: awaiting completion of an assessment; awaiting public funding; awaiting further non-acute NHS care; awaiting residential home placement or availability; awaiting nursing home placement or availability; awaiting care package in own home; awaiting community equipment and adaptations; patient or family choice; disputes; and housing.
30.The National Audit Office’s (NAO) report, Discharging older patients from hospital, found that there had been a 31% increase in bed days taken up by patients with a delayed transfer between 2013 and 2015, but that the NHS was spending around £820 million a year treating older patients who no longer needed to be in hospital. Furthermore, they noted that delayed transfers have detrimental effects on patients, affecting their morale, mobility and increasing their risk of obtaining a hospital-acquired infection.
31.The most recent data on delayed transfers covers December 2016, when there were 195,300 total delayed days; 56.2% of which were attributable to the NHS, 36.0% to social care (compared to 32.2% in December 2015) and the remaining 7.9% to both NHS and social care. Despite this data, the extent to which social care was responsible for delays was disputed. While Mark Lloyd, Chief Executive of the Local Government Association, emphasised that only a third of delayed transfers were due to the social care system, Simon Stevens, on the other hand, said:
When you get under the skin of it, it is pretty clear that, although perhaps only 40% of the delayed discharges are formally recorded in the stats as being a hospital trying to get social care for its patients, the majority of the delays are attributable to that, because the elements that are recorded as being NHS-related delays are often continuing healthcare, which in turn is about getting home care or transfer to care homes.
32.The Health Minister, David Mowat, said that there was “extraordinary disparity in delayed transfers of care between different local authorities” and that the disparity between the four worst and the four best was a “factor of forty”. He illustrated this by saying that on a recent visit to a hospital:
I was listening to the team dealing with the discharge on what is called the frailty ward, and one of the big factors that they had to discuss was whether it was council A, council B, council C or council D because, frankly, their job was quite different, depending on the arrangements that that council had and how it did its work.
The top and bottom ten authorities for average daily rate of delayed transfers in 2015–16 is shown in the table below:
Table 1: Delayed transfers of care per 1,000 population aged 65+, local authorities (2016)
Delayed transfers of care per 100,000 population aged 65+
Delayed transfers of care per 100,000 population aged 65+
City of Bristol
Newcastle upon Tyne
City of London
33.The balance of responsibility between NHS and local authority social care for delayed discharges is not clear and councils’ performance in relation to delayed discharges appears to vary across the country. This suggests the causes are many, complex and based on local circumstances, which closer working between councils and NHS partners and sharing best practice may help to alleviate in the medium to long term.
34.The Health and Local Government Ministers both denied that the pressures on the NHS were due to funding pressures on social care. Marcus Jones, Local Government Minister, said that the variation in councils’ performance on delayed discharges was not reflected in the amount of funding they had and that more integrated working was needed instead (we explore integration issues in paragraphs 37 to 39). However, Simon Stevens of NHS England told us that even if all councils performed well at managing delayed discharges, there would still be a need for extra resources in social care.
35.The NAO found that “Rising demand for services, combined with restricted or reduced funding, is putting pressure on the capacity of local health and social care systems”, and that lack of community workforce and bed capacity, stemming from commissioners under pressure keeping fees as low as possible and, in turn, putting pressure on providers, were significant causes of delays. Indeed, the NHS data show that the main reason for social care delays was lack of home care (36.9% of all social care delays). In addition, in its report on Winter Pressures in Accident and Emergency Departments, our colleagues on the Health Committee concluded that adult social care was underfunded and that this was having an impact on the NHS.
36.Even given the complexities of organisational responsibility for delayed discharges, we believe that inadequate social care funding has a very significant impact on the speed of discharges from hospital. Reductions in spending on adult social care, leading to pressure on providers and the care market and difficulties in recruiting and training staff, have led to an increase in the number of delayed discharges attributable to social care and an increase in emergency admissions of older people. The Government should provide extra funding to increase social care provision in order to relieve pressure on the NHS, as recommended by the Health Committee in its report of October 2016 on Winter pressures in accident and emergency departments.
37.Simon Stevens of NHS England was clear that some councils performed better than others, saying there were “processes that can be got right, and some parts of the country, having got those processes joined up, have seen significant improvements”. He believed that shared assessments and quick response by services to assessments had a role to play in this. Tim Hammond, the Chief Executive of Four Seasons Healthcare, one of the largest residential care providers in England, said that he could point to parts of the country where the systems were slowly becoming more joined up:
Last winter, when usually the pressures are greatest, we had around 400 winter bed contracts, as I will call them, if that makes any sense to you; they are often called step-up and step-down. If an older person has a problem at home, often the only solution for them is to go to hospital, but, actually, they could go into a care home, have skilled care for a few days or weeks before being discharged to their home. Step-down is more common. This relates to your discharge point. It is about getting people out of hospital much more quickly, freeing up the system. It is of course much better for the patient, who might just need a few days or weeks. We had around 400 of those contracts last winter versus roughly 200 the winter before. […] there are circa 50,000 empty beds in the care home sector in total. I think the NHS only has about 100,000 beds in total. The opportunity for the care home sector to really play a role in helping the NHS is very real.
We also heard about a similar project in Somerset where 18 reablement beds in one of Somerset Care’s nursing homes had been purchased by Yeovil District Hospital, into which suitable patients were being transferred, thereby freeing up hospital beds. The average length of stay was 11 days, during which patients received intensive NHS-funded physiotherapy and occupational therapy, leading to 95% of patients in the ‘reablement beds’ being discharged home and 42% having reduced support needs. The price per bed paid by the NHS of £750 per week was lower than the actual costs of care estimated at £850–900 per week.
38.Evidence from the Department for Communities and Local Government and the Department for Health described the ongoing work on improving performance, including sharing best practice and work with the NHS and local government to speed up and streamline processes, for example by promoting new models of care such as discharge to assess and trusted assessor models. The two Departments said that to access the Better Care Fund (BCF) every area has to agree a local action plan and target on delayed discharges. We note, however, the NAO’s recent findings that the BCF did not achieve this target in 2015–16 and that, although local areas had planned to reduce delays compared with 2014–15 by 293,000 days in total saving £90 million, the number of delayed days increased by 185,000, costing a total of £146 million more than planned.
39.There are many ongoing projects aimed at reducing delayed discharges and emergency admissions through closer working between the NHS and social care. Because of local circumstances and practices, what works in one area may not be as successful in another, and it takes time for new processes to become embedded. The Government, working with the Local Government Association, should increase efforts to share examples of best practice, including the use of reablement beds.
40.Stephen Dorrell, Chair of the NHS Confederation, believed that the lack of availability of home care was a “significant root cause of the rising demand trend, both of hospital admissions and of people presenting in GP surgeries”. Emergency admissions are unplanned, short-notice admissions to hospital via Accident and Emergency (A&E). The numbers of emergency admissions are rising; in 2016, the number of emergency admissions was 4.5% higher than in 2015, with an average of 500 extra admissions each day and 17% higher than in 2011. The NAO concluded that this was caused by demographic change; the increasing number of elderly people with one or more long-term conditions were more likely to need urgent care, go to an A&E department and be admitted once there. Despite the focus of the Care Act 2014 on prevention and early intervention, we heard that councils were providing less preventative care, which could also be a factor in the increasing number of emergency admissions. ADASS said:
As budgets reduce further in real terms, it is becoming harder and harder for councils to manage the tension between prioritising statutory duties towards those with the greatest needs and investing in services that will prevent and reduce future needs. As a result of this tension, this year [2016–17] councils will be spending 4% less on prevention than last year.
Carers and care users at our roundtable observed that councils were now not spending money on prevention and early intervention, even on low cost items like ramps and grab rails, despite the obvious longer-term financial benefits. The Local Government Association highlighted that the in-year cut in public health funding of £200 million had further increased the challenge to councils in investing in prevention and early intervention.
41.There are also concerns about the impact of social care budget pressures on the ‘front door’ of hospitals—emergency admissions. We are concerned that budget pressures are driving many councils increasingly to direct resources towards services for people with higher levels of needs, rather than towards prevention. Extra funding would enable councils to provide preventative services for people with lower levels of need, which is likely to reduce demand for higher-intensity, higher-cost services later on. The need for preventative services should be included in future estimates of funding needs.
42.The funding pressures on social care budgets have led to councils either freezing the fees they pay to care providers or only providing small yearly uplifts. LaingBuisson, care market analysts, estimated that, across care homes in the UK, baseline fees fell by a cumulative 6% in real terms between 2010–11 and 2015–16. The evidence we received from councils supported this: for example, Cllr Noble, Spokesman for Health and Social Care at the County Councils Network, said that his council, Suffolk, had not increased the fees paid to providers for four or five years and Lancashire County Council said their providers had received small or no fee uplifts since 2011. Professor Martin Green, Chief Executive of Care England, highlighted how low residential care fees currently are:
In some areas the fee levels are quite staggeringly low. For example, in places like Sheffield, £377 per week for residential care translates into £2.24 per hour. Consider the level of dependency of people in care services, 80% of whom have some form of dementia.
Colin Angell, Policy and Campaigns Director at the UK Homecare Association, said that his organisation had calculated a minimum price for home care at £16.70 per hour but had found that the weighted average price for home care in England was £2 per hour less, which “providers were working absolute miracles to accommodate”. The Registered Nursing Home Association said:
A typical shire County will pay a nursing home circa £560 per patient per week, that’s £80 per night. For that fee the nursing home is expected to provide 24 hour nursing care, accommodation, food, laundry etc. etc. It is no more than one expects to pay in a large budget hotel chain, and a lot less than it costs to stay at a better hotel, but the service provided is considerably different and the staffing numbers required in nursing homes is considerably greater.
43.Care providers highlighted that little or no fee increases meant they were having to absorb costs increases themselves. The main costs arose from providers’ responsibilities as employers and included: the Apprenticeship Levy; statutory holiday, statutory pensions and recruitment costs; training and development; paying for care workers’ travel and sleep-in time; and, most significantly, the introduction of the National Living Wage (NLW). They also frequently cited the registration fees they were required to pay to the Care Quality Commission.
44.Ray James, Immediate Past President of the Association of Directors of Adult Social Care (ADASS), set out the overall cost of wages in 2015–16:
Our survey this year showed that the living wage probably cost about £520 million in the first year. In addition, there were some other costs from ensuring full compliance with one or two other pieces of legislation, making sure travelling time was paid for, ensuring sleeping nights were being appropriately remunerated and things of that nature. That probably took the bill for providers for council-funded cases up to about £600 million in the year.
ADASS reported that the introduction of the NLW had “driven a very rapid increase in fees paid to providers in 2016–17”, with 82% of councils increasing fees, 42% increasing fees by over 3% and one third increasing home care providers’ fees by 5%. It is not clear whether this was also linked to the introduction of the social care precept.
45.However, care providers said that councils were not passing on the money raised by the precept via fee uplifts; for example, Four Seasons Healthcare said that, although all but eight councils raised the precept in 2015–16, only around half of the 80 councils in England who commission their services “recognised the NLW cost pressures and passed on appropriate fee rises”. In our pre-Budget report, we concluded that the precept would not raise enough to cover the increasing costs of the NLW.
46.With regards to sleep in shifts, the common approach across the care sector has been to pay a flat rate for a sleep in shift, rather than an hourly rate, which can result in care workers being paid below the national minimum wage. However, recent court judgements have come to different positions on the approach that should be taken to paying for sleep in shifts, which some of the providers who submitted evidence to our inquiry said was causing them significant financial uncertainty. The Health Minister, David Mowat, did not confirm the approach, but said that providers “could be held liable for minimum wage violations going back six years” and described the costs as “enormous”. The HMRC, however, appears to have changed its approach and now considers that every hour of the sleep-in counts for National Minimum Wage purposes. The Government should take steps to resolve this uncertainty and confirm the approach to paying for sleep in shifts. Furthermore, the Government should, with the HMRC, find a solution to the payment of back pay for sleep ins which avoids severe financial consequences on care providers.
47.Care providers use income and profit, among other things, to service debts and mortgages, invest in training staff, fund additional activities for residents, and pay for routine upgrades of the physical estate. In the context of rising costs and stagnant fees, the Care Quality Commission’s (CQC) finding that providers were finding it difficult to make a profit is not surprising. They found that providers which were reliant on local authorities for more than half of their income made on average “28% less profit per bed compared with all providers” and that “the profit margin for domiciliary care providers has continued to fall”. Care providers suggested that councils did not appreciate that providers needed to make profits; for example, care providers who were members of the Lancashire Care Association said that some councils “struggle to understand the business environment (especially around the sensitive issues of ‘profit’ and the important role of banks)” and others simply “prefer not to”. Kent Integrated Care Alliance said that the council with which it contracted had made an assumption about profit when setting a guide price for fees on the basis of insufficient and questionable data. A care provider responding to a survey by the Care Association Alliance said their council had made it clear that they “do not pay fees to providers so that they can make profits”. The provider made the observation in response that “without profits there can be NO future for this industry and certainly no reinvestment”.
48.This accumulation of pressures is posing a threat to providers’ financial viability, leading to providers failing, deciding to exit the market or hand back council contracts. ADASS said that 80% of Directors of Adult Social Care had reported that their providers were facing financial difficulties and that, in the six months to June 2016, provider failure had affected at least 65% of councils. Some of the councils that we took evidence from had experienced this; for example, Lancashire County Council said that they had experienced “unprecedented numbers” of residential, nursing and home care provider failures since April 2015. In October 2016, the CQC reported that, since 2010, there had been a 12% reduction in the number of residential (non-nursing) care homes, along with an 8% decrease in total beds—from 255,289 to 235,799.
49.Some providers are handing back contracts to local authorities: Janice Dane, Assistant Director of Early Help and Prevention at Norfolk County Council, said this happened ‘periodically’ in her area. ADASS reported that, of the 151 councils that had responded to their survey, 59 had had home care and 32 had had residential and nursing care contracts handed back in the 6 months to June 2016. In Norfolk County Council’s case, a home care provider and a nursing provider were handing back contracts because they were unable to make sufficient profit and because the nursing provider was “struggling to get the right staff”. As discussed at paragraph 21, providers are also handing back contracts if they feel unable to maintain quality of care.
50.In addition, we heard that some providers were not taking contracts on in the first place. The UK Homecare Association surveyed the UK home care market in 2014–15 and found that 50% of providers who responded had decided not to bid for tenders on the basis of price. Vicky McDermott, the Chair of the Care and Support Alliance, observed that “The concern is the people at the end of it who are left without that care. Often those people are very vulnerable”. We wholeheartedly agree. Relocation and changes in the continuity of care have significant consequences for people’s health and wellbeing and cause great concern to families and carers.
51.Care providers are on the receiving end of reductions in spending on adult social care, with councils having exerted significant downwards pressure on their fees in recent years. At the same time, they face cost pressures from the National Living Wage, auto-enrolment in work place pensions, Care Quality Commission registration fees, the Apprenticeship Levy, paying hourly rates for ‘sleep ins’ and recruitment and retention costs from high staff turnover. While the National Living Wage has the welcome effect of raising low wages in the care sector, it is adding substantially to the financial pressures faced by providers. Providers are reporting that councils are not passing on the money raised by the precept as fee uplifts to cover the costs of the National Living Wage. Central government should take responsibility for funding the costs to local authorities linked to care of initiatives such as the National Living Wage.
52.This accumulation of pressures poses a serious threat to providers’ financial viability and providers are failing, exiting the market and handing back contracts. The consequence of this for people’s care is extremely serious, and the reduction in capacity is causing delayed transfers of care. Providers’ profit margins have reduced which affects their ability to invest in the workforce and their capital assets, and deters new entrants to the market. Councils should take into account the fact that providers use profit for these reasons, as should a future review of the long-term funding of social care.
53.Care providers regularly top up or ‘cross-subsidise’ local authority fees with fees from people who pay for their own care, or ‘self-funders’. Several care providers had been advised by councils that they should subsidise the council’s fees by charging higher rates for private clients. Kent Integrated Care Alliance said their members were told that “they should look to make profits from the privately funded service users” and Brunelcare had been told their private rates “should be raised in order to subsidise the socially funded provision”. Research commissioned by the County Councils Network found that providers were seeking a growing proportion of their business from self-funders and that, in 96% of cases in a large scale sample across England, self-funders paid more than state funded residents in the same home for the same room and the same level of care. They also found that the quantum of cross-subsidy was substantial, with an average 43% premium on private payers. David Behan of the Care Quality Commission observed that cross-subsidisation depended on the wealth of the area, giving the example that an authority like Cleveland would have far fewer self-funders than West Sussex. United Response, a provider of services for adults with learning disabilities, made the point that “there are virtually no self-funders among our clients, so we cannot ‘cross-subsidise’ with private fees”.
54.We do not believe it is acceptable for self-funders to pay higher costs for the same care in order to subsidise the costs of local authority funded clients. This is polarising the market, with providers in more affluent areas more able to cross-subsidise their fees than those in poorer areas.
55.The market for care and support in England comprises many smaller local markets characterised by variations in wealth and geography; it is also notable in that within local markets councils are ‘super-’ or ‘monopsony’ purchasers of care. Various factors contribute to the overall stability of the care market. Professor Keith Moultrie, Director of the Institute for Public Care, explained that these included “demand and supply roughly being equal over time, good information on which people can base decisions about purchasing or securing services, and entry and exit to the market”. The CQC has described the care market as “fragile”, which their Chief Executive, David Behan, explained was due to increasing demand; declining supply; quality concerns; and providers failing, exiting the market and handing back contracts. He highlighted declining supply, particularly in nursing beds, as a significant issue, particularly in the context of increasing demand. Paul Simic, the Chief Executive of the Lancashire Care Association, said the market was at a “tipping point” which he attributed to funding, issues around quality, oversight and, most particularly, the workforce. We note, however, that the majority of providers are providing good quality care and that the Care Quality Commission concluded in 2015–16 that “overall quality remains good”, with 1% of adult social care services rated outstanding and 71% rated good.
56.We have already explored many of the factors outlined above in the preceding sections and will go on to look at the issues affecting the workforce in paragraphs 77 to 100. The care market is in a fragile state. Contributory factors are increasing demand, together with problems of supply, financial pressure causing providers to fail, exit the market and hand back contracts, a significant workforce shortage, deteriorating quality and increasing and unsustainable reliance on self-funders.
57.The Care Act 2014 places a duty on local authorities to facilitate and promote a diverse and high quality market for care and support services, including prevention services, for all people in their local area, regardless of who arranges and pays for those services. It is important to note that councils are now responsible for the whole of the care market, including care purchased by self-funders (it is estimated that 43% of residents of independent care homes fund the entire cost of their care, which rises to 57% if those ‘topping up’ local authority funding with private funds are included).
58.We heard this new duty described by Professor Moultrie as a huge shift in what is expected of local authorities, requiring them to maintain business and market intelligence and commercial awareness. Market shaping and commissioning are closely related and are both essential to ensuring appropriate local supply and quality of care. The guidance which accompanies the Care Act states:
High-quality, personalised care and support can only be achieved where there is a vibrant, responsive market of service providers. The role of the local authority is critical to achieving this, both through the actions it takes to commission services directly to meet needs and the broader understanding of and interactions it undertakes with, the wider market, for the benefit of all local people and communities.
59.This guidance also sets out the principles and steps that councils are expected to follow in shaping the market and commissioning. The principles include focusing on outcomes and wellbeing; promoting quality services, including through workforce development and remuneration and ensuring appropriately resourced care and support and supporting sustainability. The steps councils are expected to follow include engaging with providers and local communities and securing supply in the market and assuring its quality through contracting.
60.We heard that best practice in market shaping involved the creation of “longer-term partnerships and relationships with providers that can build in security and minimise risk of breakdown within the market”. Norfolk County Council said that they invest a lot of time and effort into market shaping: “We have a comprehensive market position statement […] annual care conferences and local provider forums”. ADASS South Eastern Region described:
Work[ing] closely with providers to ensure the market responds to emerging need, required service developments and changing practice. This is achieved through contract review process, ongoing discussion, events and workshops, joint work and mechanisms such as the production of Market Position statements.
61.However, a survey of councils by the Local Government Association (LGA) suggested that not all felt able to shape the market; only 15% of councils who responded felt that they “understand and can fully shape their markets to deliver choice, diversity and quality” and 81% felt that they could only “partially influence” the market. The LGA said that many cited funding pressures, the National Living Wage and recruitment and retention as prohibiting factors. We also heard that councils’ ability to shape the market was linked to the number of self-funders in an area: where an area had a high number of self-funders, the council’s ability to influence the market was limited as providers were not dependent on local authority funded clients: the reverse was the case in areas with few self-funders. The County Councils Network said there was evidence of a “‘two-tier’ polarised market, with providers seeking an ever increasing proportion of their business from higher fee paying ‘self-funders’, locking out local authorities from accessing segments of their local market”.
62.Care providers were often critical of councils’ market shaping practices; for example, Surrey Care Association said that, in its area, market shaping was “underdeveloped and ineffective” and Martha Trust said:
Our feeling is that behind the façade of consultation there lies no substance and the authority has already made its own decision ahead of the consultation. Market oversight is patchy. Authorities have some knowledge of local markets but communication within and between teams in their structure can be less than perfect. Market development initiatives in general appear at first sight to be inclusive but in practice the motivation is self-centred on the part of local authorities with, in reality, little regard for the opinions, needs or ethos of providers.
In addition, the lack or poor quality of market position statements was often noted. Care England said:
Largely, these do not account for the impact of cuts to social care, nor do they explain where savings will be made. While they demand a lot from providers, they rarely outline gaps in the market, the impact of staff shortages, a long view of changing demography, or propose concrete solutions. Few offer any analysis of local workforce needs.
A separate LGA survey of providers in February 2016 found that 68% of providers had regular contact with their local authority through a provider forum or equivalent and around 50% said that discussions with councils on commissioning priorities and plans were “very or fairly effective”. We heard that the funding pressures experienced by councils, and in particular the impact this has had on fees, were a direct challenge to relationships with providers and councils’ ability to fulfil their market shaping duties. Heritage Care Group said that:
Our experience, given the constraints on local authority budgets, is that there is a tension between the strategic planning aspirations detailed in market positioning statements and acute funding pressures forcing Authorities into short term cost management approaches.
63.Councils are statutorily responsible for shaping the care market to provide diverse and high quality care for all people in their local area, including self-funders. Successful market shaping by councils involves local engagement and developing trusted relationships and regular dialogue between providers, service users and other partners. However, funding pressures are undermining the relationships between councils and providers, thus affecting councils’ ability to work with them to shape the market. Councils should be reminded that their market shaping responsibilities extend to and include oversight of the financial viability of their local providers.
64.As nearly all care services are procured from the independent sector, commissioning is a very significant part of the care system. Care Act guidance sets out the wider implications that commissioning has for quality of care and the workforce:
[Local authorities should] assure themselves and have evidence that contract terms, conditions and fee levels for care and support services are appropriate to provide the delivery of the agreed care packages with agreed quality of care. This should support and promote the wellbeing of people who receive care and support, and allow for the service provider ability to meet statutory obligations to pay at least the national minimum wage and provide effective training and development of staff. It should also allow retention of staff commensurate with delivering services to the agreed quality, and encourage innovation and improvement.
Despite this significant role, the evidence suggested that the standard of commissioning ranged very widely, and a significant proportion of the evidence we received indicated that, in some areas, commissioning practices were poor. For example, a survey by the Care Association Alliance reflected this: 58% of its members that responded rated their authorities as either ‘poor’ or ‘extremely poor’ at commissioning and only 10% rated them as ‘good’. We note evidence that churn in council staff has made it difficult to maintain provider-commissioner relationships and led to loss of commissioning skills.
65.Deteriorating relationships between providers and councils were hindering commissioning as well as market shaping. According to Avenues Group, “lack of communication and collaboration” was a “barrier to effective commissioning”. Other providers said that councils conducted their commissioning in a hostile manner. Surrey Care Association said that the council’s contact with providers was “procurement-led” and “directive, harsh and commercial in its approach” and Martha Trust said commissioning practices were “not just tough and a search for value” but “inflexible, out of touch, unrealistic and defensive”. Humberside Independent Care Association said:
One local authority chose not to hold consultation meetings with providers regarding rates for 2016–17 and reached their decision based on discussions with other local authorities and the available budget. Other local authorities did not make it easy for providers by refusing to share their pricing mechanism without pressure from providers.
66.The Care Association Alliance said that the most negative interactions between providers and commissioners revolve around fees, which is perhaps unsurprising given that, in response to funding pressures, councils have either frozen fees or are providing small yearly uplifts (see paragraph 42). We heard that lowering fees had become a driving factor in commissioning for some councils, with some using ‘e-auctions’ in which the lowest bidder won the contract. This is contrary to Care Act guidance that fee levels should be appropriate to deliver quality care and allow providers to pay staff at least the national minimum wage and provide training and development. We heard that councils were increasingly taking a “price first, quality second approach” and Brunelcare said that “over the last five years the balance between quality and price has shifted from 70:30 to 50:50” leading to them deciding to withdraw from several bids. Professor Green, Chief Executive of Care England, told us that:
There is a misnomer in talking about negotiations with local authorities. The vast majority of local authorities have a set budget and the negotiation is about going down from a figure, not identifying what the true costs of care are.
On the other hand, there was evidence that some providers were placing low fee bids which, in some cases, were financially unsustainable and led to them handing back the contract. Janice Dane of Norfolk County Council said, however, that her council would not accept the lowest price and would question whether low prices covered care workers’ travel time.
67.The Care Act guidance suggests that, to guide fee setting, authorities should have reference to three costs of care models: UK Homecare Association Minimum Price for Homecare, the LaingBuisson Fair Price toolkit and the ADASS Paying for Care calculator. Essex Independent Care Association said that, in collaboration with other providers, it had carried out a costs of care exercise and that:
The costed models produced figures which were well in excess of those currently being paid by the local authority. Both domiciliary care and residential care providers have been informed by the local authority that their budgets do not allow for the costed models to be adopted and they can only pay what their budgets permit.
However, Lancashire Care Association said that developing a fair price model had been a positive development for its local care market, and Tim Hammond, the Chief Executive of Four Seasons Healthcare, said it would be helpful to have an agreed, transparent method of working out the costs of care across the whole country.
68.Funding pressures have similarly affected the commissioning relationship between councils and providers. The pursuit of low fees has become the driving factor in commissioning for some councils, despite Care Act guidance that they should be appropriate to deliver quality care and allow providers to properly remunerate and train staff. A standard process for assessing the costs of care, which takes into account local variations in wage rates, and setting fair prices that reflect costs, would help guide local authorities. It should focus on key services such as residential care for older people and home care, be designed by an independent body and agreed by provider representatives and councils through the Local Government Association, the Association of Directors of Adult Social Care, and the Department of Health.
69.As in any procurement process, care providers are expected to bid for care services contracts. Some providers were critical of the tendering process, saying that it was a slow and costly exercise. Several tendering processes that Brunelcare had taken part in had been delayed and eventually extended to two years, over which time they estimated the costs of their input had amounted to £51,000. They also said that tenders were increasingly cost rather than quality focused and that recently one had been “very onerous and probably beyond the capacity of many small providers”. Similarly, Lancashire Care Association argued that substantial resources are wasted in “overly complex and burdensome tendering processes”. Concerns were also raised about delays in re-tendering, leading to short-term rollovers of contracts which inhibit providers’ financial planning. Providers also said that councils were using tendering and commissioning processes as a way of monitoring providers for quality and safeguarding, duplicating the work of the CQC and adding to existing regulation.
70.Professor Moultrie of the IPC said that the type of contracts used by councils to commission care “minimise[d] transaction costs”, enabling councils and providers to “spend more time on outcomes”. Some providers, however, felt contracts were aimed at ease of commissioning and efficiencies, rather than ensuring quality of care or a diverse market unfair. Others felt that contract terms were unfair, but said that they were often not in a position to argue. For example, Exalon Autonomy Group said:
[Learning disability] residential placements are usually agreed using a framework agreement between the provider and the local authority. These agreements are drafted by the [local authority], and are non-negotiable—it is a case of “take it or leave it”, leaving the provider with no choice if it wants to continue in business. In our experience such agreements give the local authority carte blanche with regard to fee uplifts (or even reductions) and are woefully deficient in providing for dispute resolution when it comes to fees.
We also heard that some councils were using per-minute billing or ‘banding’ for home care contracts. Colin Angell, Policy and Campaigns Director at the UK Home Care Association, said this meant that “You might work 25 minutes, but because it was not 30 minutes, the authority would round the time down to 15 minutes of pay”.
71.When we asked whether it would be possible for councils to contract on the basis of outcomes and quality rather than price, José-Luis Fernández, Deputy Director of the Personal Social Services Research Unit at the LSE, said that there was a lot of interest in the issue but that it was very difficult. Janice Dane of Norfolk County Council explained why:
In terms of contracts, outcomes are hard. It is far easier to buy chunks of time and tasks than it is to work with outcomes. That is an area in which we are trying to improve, but it becomes very difficult to know when those outcomes have been achieved, who decides that and how to trigger the payment.
The Botton Village Families Group had experienced changes in the way the care was provided to their relatives which greatly concerned them and, as a result, suggested the Department issue guidance on the Care Act and other relevant legislation to ensure quality in provider-commissioner contracts.
72.Our witnesses agreed with calls from provider bodies for oversight of local authority commissioning. Professor Green, Chief Executive of Care England, said he had:
Advocated an oversight role for a long time, because it is about the only bit of the system that is not accountable to anybody for its performance […] Every stage at which there is a requirement to do something, the rest of the system is locked down, quite rightly, by someone with oversight. The local authorities are not in that space. There is a real problem about not having that element of the system properly monitored for outcomes and performances.
73.As nearly all care services are procured by local authorities from the independent sector, commissioning is a very important part of the system. There was significant evidence from providers about poor practice, unfair contracts and depleted commissioning teams. The market shaping, commissioning and procurement activities of councils are the only part of the system which are unregulated, yet they have a direct impact on the quality and diversity of care people receive and the sustainability of the sector. The Care Quality Commission’s remit should be extended to include oversight of these activities, as well as the extent to which councils comply with the fair costs of care in their negotiations and contractual relationships with providers. It should also work with the sector to produce best practice template contracts for the provision of care services. The Department of Health should also review the guidance on commissioning which accompanies the Care Act 2014.
74.The councils often described the quality assurance arrangements they had in place to monitor the services they had commissioned. However, the undercover investigation undertaken by the Channel Four Dispatches programme demonstrated that such arrangements were far from infallible. Their investigation revealed that home care workers in Haringey were being paid below the national minimum wage, despite Care Act guidance saying that councils should assure themselves that the minimum wage was paid. Heather Wakefield, National Secretary for Local Government at UNISON, said that a survey of councils by her organisation had found that around 70% did not monitor contracts to ensure payment of the national minimum wage and quality of care.
75.The evidence we have heard suggests that not all councils routinely monitor the care services they procure to ensure that they are sufficient to meet people’s needs, and are of a high enough quality and adequately resourced, for example to pay for care workers’ travel time and ‘sleep ins’. Councils should undertake annual auditing of the services they commission and the Care Quality Commission’s extended remit should also oversee councils’ arrangements for monitoring the care services they have purchased and the effectiveness of that monitoring.
76.The Channel Four Dispatches programme further highlighted the difference between the care councils were commissioning and the actual delivery of it. Their investigation, which included secret filming and freedom of information requests to councils, found large numbers of late, missed and truncated home care visits and errors in administering medicines. We heard evidence about the increasing potential for councils, carers and relatives to use digital technology, which we explore in paragraph 146, to verify that care has been delivered. Councils should regularly carry out ‘spot checks’ to ensure that people are actually receiving the care they require and be alert to new technological developments in this area.
77.A substantial proportion of the social care workforce consists of people who have worked as care workers for many years. According to Skills for Care’s dataset, workers had, on average, eight years of experience in the sector and around 70% of the workforce had been working in the sector for at least three years.
78.As discussed in paragraph 17, the size, calibre of the workforce and, linked to this, the standard of their employment, is key to ensuring quality of care; as Sharon Allen, Chief Executive of Skills for Care, said, “to provide genuinely person-centred care and support, you have to treat your workforce in a person-centred way as well”. An adequate workforce is also essential to meeting demand for social care in the coming years and it is estimated that another 275,000 people will be needed to work in the sector by 2025. However, in 2015, 6.8% of roles (84,000 jobs) were vacant and the turnover rate for all directly employed staff working in social care was 27.3% and 35.9% among nurses working in social care. A large proportion of staff turnover is a result of people leaving the sector soon after joining (47.8% of care workers left within a year of starting). This points to severe challenges in maintaining staffing levels and we explore the evidence for this in the paragraphs below. In addition, we heard concerns that, as 7% of the overall social care workforce is from the EU, rising to 10% in the South East and 12% in London, the recruitment and retention challenge may increase.
79.Our witnesses were concerned by the lack of recognition afforded to care work. Sharon Allen of Skills for Care said:
One of the most important things we can do is to address the image, the profile and the status […] I am often frustrated to hear people conflate low pay with low skill and low value. Most people working in adult social care are undertaking very skilled roles and they need high skills and personal attributes and high levels of resilience to be able to do what they do.
This was also a common theme among the care workers who posted comments on our online forum, one of whom said “it is more often or not a job of last resort, rather than a job of choice […] we are not respected, valued or recognised”. Another said that there needed to be a national campaign valuing the work that care workers do.
80.Care workers’ pay is very low and payment of sick pay and pensions is not universal. Skills for Care collects employment data for the sector, including the yearly and hourly rates of pay. The current full time median annual pay and median hourly rates are:
Table 2: Full time median annual pay and median hourly rates, 2016–17
Median annual pay
Median hourly rate
Senior care worker
Skills for Care provided further data to the Committee showing that care worker pay decreased in real terms by around 6% between 2009 and 2016, suggesting that the impact of the funding pressures of social care budgets passed from councils to provider fees and onto staff wages. A care worker who contributed to our online forum said:
We have bills to pay and families of our own to look after. Our pay packets do not reflect the valuable and NECESSARY contribution we make to society. I do love my job but with it comes responsibility, unsociable working hours, & loads of training and working towards qualifications. We are undervalued … And often overlooked.
Despite static or declining wages, the complexity of the work had increased. Colin Angell, Policy and Campaigns Director at the UK Home Care Association, said home care workers were becoming more like district nurses and undertaking tasks not previously expected of them”. Witnesses observed that the low rates of pay and challenging nature of the work meant that people often preferred to work for the same pay in less stressful jobs in retail or leisure.
81.Pay levels are also affected by the practice of only paying care workers for the time they spend with clients, and not the time spent travelling between clients, handovers, training or ‘on-call’ hours in home care and residential care. The National Audit Office has estimated that as many as 160,000 to 220,000 care workers in England are paid below the national minimum wage because of the practice of only paying for ‘contact’ hours. A survey of councils by UNISON found that only 35% of councils in England make it a contractual condition that their home care providers pay their workers for travel time. A care worker who contributed to our online forum said:
I love what I do but to be paid the hours I am actually in uniform and at work instead of just for the calls I do would be lovely. I don’t know many other jobs that you work 14 hour split shifts but only earn 10 hours money. […] I do roughly 12,000 miles a year for work … that’s a set of tyres.
82.UNISON has created an ‘Ethical Care Charter’ aimed at improving standards the home care sector. It has been adopted by 26 councils which have committed to ensuring that there is continuity of care, ending 15 minute visits for personal care, paying staff a living wage and ensuring that they are paid for their travel time. The union reported that some of the councils that have adopted it have experienced improved recruitment and retention rates and staff morale leading to better services and outcomes for the people receiving care.
83.While all our witnesses welcomed the intention behind the National Living Wage (NLW), we heard evidence that the practical consequences of the rise in pay were challenging for providers. Firstly, in that it is not being reflected in the fees paid by councils to providers (which we explored in paragraph 42) and, secondly, that it made it more difficult for employers to differentiate between staff levels. Sharon Allen, Chief Executive of Skills for Care, summed up the situation:
Everybody supports raising up the pay of the lowest-paid workers. People would like to pay their staff more but they can only afford to pay what is in the commission, and then the differential to then move up to being a team leader, a senior or a registered manager becomes less attractive because the national living wage is driving up the entry pay.
Similarly, the Voluntary Organisations Disability Group said it had “flatten[ed] out the differential that many providers have sought to achieve to make social care an attractive career of choice. For providers, this would be an increasing concern as the NLW rises over the coming years. In addition, we heard that, having equalised pay across a broader range of employers, the NLW had increased the competition for staff with other sectors, where, as we highlighted earlier, the work may be less stressful.
84.We heard that the NLW would not make a difference to the challenges of recruiting and retaining a high calibre workforce, capable of the demanding work involved and that it was “not enough to be commensurate with the skills and responsibilities required”.
85.We were also told that working patterns, as well as wages, directly affected care workers’ job satisfaction and the quality of care they provided. According to Skills for Care, 24% of care workers (315,000 people) were recorded as being on zero hour contracts in 2015, compared with 2.9% of the workforce nationally. Home care had the highest proportion (49%) of workers on zero hour contracts. While some witnesses thought that flexible working arrangements could suit some workers, others believed that these contracts hindered recruitment and retention and quality and continuity of care. A contributor to the online forum who had previously worked on a zero hour contract said that, now they had a full-time contract, they were enjoying their work a lot more. Sharon Allen of Skills for Care said that the key issue was whether care workers were offered genuine choice in the matter.
86.No qualifications are required for work in social care, which makes the provision of training for care workers important. A survey of a thousand care workers conducted by UNISON in 2015 found that 27% had received no dementia training and that, of those that administer medication, 24% had received no training. Heather Wakefield of UNISON said “there isn’t a sense that this is a job you can go into and really develop your skills. People do it by looking at a video or just learning on the job”. The Cavendish Review found in July 2013 that “Training is neither sufficiently consistent, nor sufficiently well supervised, to guarantee the safety of all patients and users in health and social care”. We also note that the undercover reporter in the Channel 4 Dispatches documentary was allowed to pay home visits to clients alone after only three days of shadowing.
87.We heard that more than 70% of councils do not include an element for training in the fees they pay to providers, despite the statutory guidance that councils should assure themselves that fee levels should provide for “effective training and development of staff”. Providers said that lack of funding was affecting their ability to recruit, train and pay staff to a level that would meet the increased level of needs of their clients. Clare Jacobs, Employment Relations Advisor at the Royal College of Nursing (RCN), identified the further challenge that:
Most social care is provided by smaller providers, which on the basis of economies of scale just do not have the resources to put in a training and development package or to employ people to do training and development. You have lots and lots of small providers, and it is not something that is centrally funded or provided, so there is a huge training and development gap in the market.
The Department for Health funds a Workforce Development Fund from which providers can claim for the costs of learning and development, but we heard that this was heavily over-subscribed and not used by all organisations.
88.The challenges facing the care workforce appeared to be more acute for nursing in social care. Skills for Care’s data revealed that, despite a rise of 3% in 2012, the number of nurses working in the adult social care sector decreased by 4% between 2011 and 2015, reducing from 49,000 to 47,000. The vacancy rate of registered nurses was high, at 9.2%, an average of 4,300 vacancies at any one time, and the annual turnover rate was also high, at 35.9%.
89.Providers described struggling to recruit the number of nurses they needed, with some having consistently high numbers of vacancies and some waiting up to two years to fill them. Guild Care said that, as a result, they had had to rely on agency nurses at a cost of one third more per hour than their employed nurses. This situation may be contributing to the decline in the number of nursing beds across the country as nursing homes either exit the market or convert to care homes. Janice Dane, Assistant Director of Early Help and Prevention at Norfolk County Council, said that, in the last 16 months, there had been a reduction in nursing beds in seven different homes from which her council commissioned care: this was equivalent to a 5% reduction in the beds available.
90.In 2015, registered nurses were paid a mean annual salary of £25,000, which is within the NHS’ ‘band five rate’, above which there are 8 further pay bands. While social care nurses earn significantly more than care workers, they earn less than their counterparts in the NHS and do not have access to the other opportunities that working in the NHS affords, such as the NHS pension and career progression. As a result, providers said it was difficult to compete with the NHS for staff and that they were losing staff to the NHS.
91.Clare Jacobs of the RCN highlighted the importance of the role of social care nurses with the workforce: “Nursing has unique knowledge, skills and professional accountability to assess clients adequately, and manage and evaluate their care”. Furthermore, there was an increasing need for nurses in social care as demand and the complexity of people’s care needs increases.
92.The workforce is essential to quality of care. High vacancy and turnover rates point to severe challenges. A range of factors are responsible, including low pay not commensurate with the level of work involved, low status, poor terms and conditions, and lack of training opportunities and career progression. Vacancy and turnover rates are particularly high among social care nurses, who understandably prefer the better pay and conditions and career development in the NHS.
93.Non-payment of the national minimum wage is widespread as a result of providers failing to pay care workers for their travel time, travel costs and ‘sleep in’ shifts. When commissioning care, councils must ensure that providers pay enough to comply with the national minimum wage and to cover care workers’ travel time and costs and ‘sleep ins’. Contracts between councils and providers should stipulate this and councils should regularly monitor compliance.
94.The Government, working with the Local Government Association, should publish a care workers’ charter, drawing upon UNISON’s Ethical Care Charter, which sets out what care workers can expect from their employer. Employers should be expected to demonstrate their commitment to supporting and developing care workers.
95.The National Living Wage, although welcome in a low paid sector, will not be sufficient to bring pay into line with skills and responsibilities or to improve vacancy and turnover rates. It has increased competition from less stressful jobs in other sectors and made it challenging for providers to differentiate pay between staff levels. Provision of additional funding for social care would enable providers to pay staff wages above the National Living Wage and provide staff with training. The Government should request that Skills for Care, in discussion with unions and providers, conducts research to determine what level of wage is needed to sustain the workforce and attract new entrants.
96.The Government should encourage local authorities and their NHS partners to develop local joint strategies for recruitment and retention of social care nurses and to reduce competition between sectors for staff. Ensuring adequate nursing capacity in social care is essential if councils are to be able to support hospitals in the prompt discharge of patients.
97.Social care users can opt to receive a direct (cash) payment so they can choose which services they purchase, which can include employing a personal assistant (PA). However, some of the direct payments recipients that we spoke to at our round table event said they had received no support from their local authority on recruiting and employing staff and consequently found the responsibility of being an employer a burden. Anna Severwright, who gave evidence to us, said:
There is not much support from my local authority if I have an issue with a PA; I am kind of left to sort it all myself. It has been a steep learning curve in how to be an employer, because I had never done that before.
UNISON said that care workers employed in this way can find themselves in “a precarious position at work, with their employment rights often not properly observed”. Sharon Allen of Skills for Care said that support for individual employers and PAs had actually increased and that the challenge therefore was people often not realising they had become an employer. She said that more needed to be done to make people aware of this and then to direct them towards support. We agree. Direct payments are a great opportunity for people to take control of and personalise their care. However, councils must ensure that people are comfortable with and able to take on the employment responsibilities that direct payments entail and guide people to sources of support and advice on being an employer.
98.We asked our witnesses what needed to be done to improve recruitment and retention in social care workforce, they had a number of suggestions linked to solving the challenges set out above. We heard that addressing the image, profile and status of the job was the key priority and that there was a “better story to tell” about the high level of skills and personal resilience needed to be a social care worker. Alongside this, there needed to be a career structure which afforded care workers opportunities for progression (much like the NHS Knowledge and Skills Framework), better training, further investment in qualifications, and fairer pay, terms and working conditions.
99.Simon Stevens, the Chief Executive of NHS England, outlined some recent positive developments:
One of the things we are committed to doing is creating more ladders of opportunity for people from care assistant jobs into the new nursing associate role, and then from the nursing associate role into being a registered nurse. That […] is one of the ways in which we can make the care assistant role important, not only week in, week out, but as a career path that leads to advancement.
100.The status of care work must be improved to ensure a high quality and sustainable workforce which keeps pace with demographic change. Better pay, commensurate with skills and responsibilities, and better terms and conditions, including pensions, will be part of this, as will the development of a strong career structure—from apprenticeship to registered nurse—and centrally delivered training with national standards and qualifications, similar to the NHS Knowledge and Skills Framework. The Department of Health should consider whether a national recruitment campaign, similar to Teach First or Step Up To Social Work, would be an appropriate mechanism to achieve this and whether care work should be designated a registered profession.
101.Carers are entitled to assessments of their own needs for support, including those relating to education, employment and training, and to have those needs to be met. We explore the take-up of carer assessments at paragraphs 106 to 109 and the provision of support in paragraphs 110 to 114.
102.Research by Carers UK found that, between 2010–11 and 2013–14, the number of unpaid carers had increased by 16.5% (compared to an increase in the general population of 6.2%), that the number of people providing 20–49 hours of care a week has increased by 43% since 2001 and that the number of people caring for fifty or more hours per week had increased by a third. They attributed this to a decrease in the amount of care and support provided by councils in the context of increasing need (this issue is covered in paragraphs 8 to 16). This suggestion was supported by the evidence we received from people who receive social care and from the unpaid carers we took formal evidence from or spoke to at our informal roundtable.
103.Councils often acknowledged the important contribution made by carers; for example, ADASS North West said, without their “vast contribution”, the care system would “be bust”. Cllr Palmer, Lead Member for Adult Social Services at Leicester City Council, said that some families in his authority area were reporting that changes in care packages had led to an “increased level and scope of responsibility and pressure on unpaid carers and families” which he said was a real challenge to local government. In contrast, Surrey Care Association said their council’s “stated policy” was to use family, friends and community to provide unpaid care.
104.At a time when the system’s reliance on unpaid carers is increasing, we heard that a “care gap” was emerging. Dr Linda Pickard, Associate Professorial Research Fellow at the LSE, said that:
[A] shortfall in intergenerational carers is projected to emerge in 2017 […] and will grow rapidly from then onwards. The shortfall will amount to approximately 15,000 care providers in 2017, 50,000 in 2022, 105,000 in 2027 and 160,000 in 2032. The shortfall will mainly affect intergenerational care provided by children to their older parents.
She explained that demographic change meant that “numbers of older people aged 85 and over in the UK are rising much faster than numbers in the younger generation aged 50 to 64”, while the number of ‘spouse carers’ was likely to keep pace with demand due to improvements in male mortality. Furthermore, carers are ageing; the number of carers over the age of 65 has risen by 35% since 2001, compared with a rise in the total number of carers of 11%. We note the challenge this poses to the Health Minister’s suggestion that society should start thinking more about the role of children in looking after their parents.
105.The social care system is heavily, and increasingly, reliant on unpaid carers. As councils have reduced the amount of care they supply, unpaid carers have stepped in to fill the gap, providing more hours of higher level care. However, demographic changes mean that a growing shortfall in intergenerational carers is projected, which poses a challenge to the suggestion that children may need to care more for their parents in future. It is clear that, unless social care receives more funding, the system will not have the capacity to fill the shortfall in the future.
106.The Care Act requires councils to identify, assess and meet a carer’s needs for support, if they are financially eligible, and in doing so have regard to whether they are in work, education or training or would like to be. While it was evident that councils take their duties towards carers seriously, we heard that such duties presented challenges to councils, firstly, in terms of identifying carers and, secondly, in meeting the costs of carers’ assessments.
107.Cllr Palmer of Leicester City Council said that, although 30,000 people had identified themselves as a carer in the 2011 Census, only 2,200 carers were in contact with the council. This was also the case for Lancashire County Council, which had only a “small proportion” of the carers identified in the 2011 Census on their database. We heard that the reasons for the difficulties in identifying carers could be cultural, apprehensiveness on the part of the carer as to what an assessment might entail or because they did not realise they were a carer.
108.However, Peter Turner, Chief Executive of Carers First (Kent and Medway), said that councils had an incentive not to identify carers due to the cost implications, and we received evidence from councils highlighting the costs of carers’ assessments and the added pressure this put on their social care budgets. Cllr Palmer said that, while his council did actively seek out carers for support:
If half of those 20,000-odd carers […] came forward, and two-thirds of them were eligible for support, let me put it in absolutely straightforward terms: that would essentially bankrupt my local authority. It is as black and white as that. That presents a real tension and quandary. We do go out there and seek carers to come forward, to support them.
109.Dr Pickard of the LSE said that research on carers’ assessments had shown that managers and practitioners may be “rationing access to carers’ assessments due to resource constraints” and that councils are tending to focus on assessing carers with the most intensive caring responsibilities or “virtually round-the-clock caring”. Furthermore, Vicky McDermott, Chair of the Care and Support Alliance, said that carers were being told by their council, “If you have a couple of quid, we are not going to bother doing the assessment”. Peter Turner said that the incentive to reduce the number of carers’ assessments was “perverse” because carers were at the forefront of “keeping people out of hospital beds, residential care homes and GP surgeries”. Some of the carers who attended our roundtable event expressed concerns about the assessment process saying that they had found it be a box-ticking exercise and that council staff carrying out the assessment did not really listen to or empathise with them.
110.Support for carers takes various forms; equipment at home, such as help from care workers or ‘replacement’ or ‘respite’ care to enable the carer to have a break. There was significant evidence that support for carers was not readily available. For example, Carers UK said that 20% of carers who were providing 50 hours or more of care each week were receiving no practical support. A Freedom of Information request to councils by Revitalise showed that, between April 2015 and April 2016, 42% had reduced their spending on respite care by an average of £900,000 each. Day centres are also an important way to provide respite for carers, but have been similarly affected by the funding pressures. Margaret Dangoor, who cares for her husband, who has advanced dementia, told us that:
Our caring cafe used to be held every Saturday. It is now every other week, and even then there are murmurings asking how they are going to keep it going, because of funding. These core services are really respite, because the person with dementia comes along with the carer, and then we have an opportunity to go into a little meeting on our own.
Even where respite care was available, there were concerns about its quality. Independent Age said that some carers refused respite care because of its poor quality and that those who did accept it “felt a sense of unease and worry that [it] would not be adequate”. The Alzheimer’s Society’s helpline reported that:
[A lady] with dementia was supposed to go into respite for three weeks, but the care home didn’t understand her medication needs. The carer had to go in every day and ended up taking her home after a week and a half.
111.Emily Holzhausen of Carers UK said that people were providing more care “without the kind of backup and support that they need in order to keep healthy and well”. Her organisation said that carers were suffering from physical injuries and mental ill-health, were less likely to be able to look after their own health and were likely to be socially isolated and depressed. A residential care provider told us the carers of people who are admitted to their home are often “at or near the point of exhaustion”. A contributor to our online forum said carers suffer with “stress, burnout, vitamin D deficits, back and muscle problems from lifting without support”.
112.In addition, we heard that caring could have a negative effect on a person’s ability to work, which is accentuated if the cared-for person receives no support services. Carers UK’s 2016 State of Caring Survey found that half (49%) of carers who responded had given up work to care, 12% had retired early, 23% had reduced their working hours and 17% opted to take a less qualified job or turned down promotion. One of the carers who contributed to our online forum said “I care for my mother and my aunt, try to keep a part-time job too, and have a partner. Through my care role I have lost my house, full-time job, car, friends, quality of life, health”. Another said that to combine caring for her mother with work they had taken a less stressful job but with lower wages.
113.The Care Act requires councils to identify, assess and meet a carer’s needs for support, if they are financially eligible. However, councils said that the costs of assessing and supporting carers have significantly added to the pressure on their budgets. This places both local authorities and carers in a very difficult position.
114.Caring, particularly as it becomes more intensive, has serious consequences for a carer’s own physical and mental health. The support for carers which could prevent them from becoming unwell, such as respite care, is being reduced or is simply not on offer, despite duties in the Care Act which require councils to consider carers’ health and wellbeing and meet their needs for support. Extra funding is needed to enable councils to fulfil their duties to assess and support carers and, in so doing, maintain their health and well-being, participation in education and employment and ability to continue caring.
115.Research by the LSE in 2012 indicates that the public expenditure costs of carers leaving employment in England are at least £1.3 billion a year based on lost tax revenues and the cost of Carers Allowance. Dr Pickard of the LSE said that there was evidence to show that carers were more likely to be in work if the person they looked after received care services, such as home help, home care, help from a personal assistant, day care, meals and short-term breaks or respite. In addition, we heard that having a “care friendly employer” who was supportive, flexible and understanding was important to a carer continuing in work but that recognition of carers in the workplace was “in the sphere childcare was in 20 years ago”.
116.During its visit to Berlin, the Committee learnt about the Pflegezeitgesetz (the Caregiver Leave Act 2008) and the Familienpflegezeitgesetz (the Family Caregiver Leave Act 2012), which introduced a legal framework to reconcile the responsibilities of long-term caring and work. Depending on the size of the employer, this legislation allows carers to take short- (10 days) and longer-term (up to 24 months) periods of leave to care for a family member, on a full- or part-time basis. Carers are entitled to claim a wage compensation benefit (or ‘carer’s grant’) for the shortest-term period of leave and, for longer-term periods of leave, are entitled to financial support in the form of an interest-free loan from the Federal Office of Family Affairs and Civil Society Functions. In England, carers are entitled to request flexible working but have no dedicated employment rights.
117.Combining caring responsibilities with employment without extra support is particularly challenging. The Care Act requires councils to take carers’ work and education into account in the provision of support, yet many carers are having to leave work, which is detrimental to their longer-term financial security and a significant cost to the public purse. We look forward to progress on the Health and Work Green Paper and the Fuller Working Lives Strategy which the Minister indicated would look at how carers might be better supported to enter, stay in and return to work. As part of this the Government should consider whether the approach taken in Germany to carers’ leave might be a basis for giving carers dedicated employment rights.
118.Financial support is also available to carers through the benefits system: Carers Allowance is £62.10 per week for providing at least 35 hours of care a week to someone in receipt of certain disability benefits. Carers cannot claim the benefit if they earn more than £110 a week (after deductions). Carers who contributed to our online forum were unhappy with the level of the benefit. One contributor said it “is an insult, and keeps people doing an amazing job poor and having to make choices about whether to heat or eat”. Another said “Since reaching 65, my Carers Allowance has reduced to just £34.50 a week, though I am [caring] for upwards of 100 hours a week”. Another said she was surprised to find that, even after taking a lower paid role to accommodate caring for her mother, Carers Allowance was means -tested. Independent Age said there was a “clear need for the government to review how it financially supports carers and recognises carers’ contributions through the social security system”. In light of this evidence, we were pleased that the Minster for Disabled People said that her Department was considering the earnings limit for Carers Allowance, that the “logic of raising [it] is there for all to see” and that the level of the benefit would be considered in the Health and Work Green Paper.
119.Carers Allowance should be increased to reflect the increasing contribution that carers make to the social care system. In addition, the earnings limit should be higher and more flexible to enable carers to maintain some contact with the labour market.
9 Qq4–5, 387
10 Care Act 2014,
11 NHS Digital, Community Care Statistics, Social Services Activity, England (2009–10 to 2015–16)
12 Age UK ()
15 The Care and Support (Eligibility Criteria) Regulations 2015,
18 Age UK ()
19 Age UK, 1.2m older people don’t get the social care they need, 17 November 2016
23 Care Act 2014,
24 [Larry Gardiner]
25 Scope ()
28 Association of Directors of Adult Social Care ()
32 Association of Directors of Adult Social Care ()
35 Care Quality Commission, The State of health care and adult social care in England 2015–16 (October 2016)
36 Care Quality Commission, The State of health care and adult social care in England 2014–15 (October 2015)
37 Care Quality Commission, The State of health care and adult social care in England 2015–16 (October 2016)
39 For nursing and residential homes, small comprises 1 to 10 beds.
43 Cambridgeshire County Council, Essex County Council, Hertfordshire County Council, Norfolk County Council, Suffolk County Council, Southend Council and Thurrock Council ()
44 Association of Directors of Adult Social Care ()
45 Humberside Independent Care Association ()
46 Mandy Abbey ()
49 NHS Digital, Personal Social Services Adult Social Care Survey 2015–16 (September 2016)
53 Relatives and Residents Association ()
54 Independent Age ()
58 Care Quality Commission, The State of health care and adult social care in England 2015–16 (October 2016)
59 Association of Directors of Adult Social Care ()
62 NHS England, Monthly Delayed Transfer of Care Situation Reports: Definitions and Guidance (updated October 2015)
74 Health Committee, Third Report of Session 2016–17, Winter Pressures in Accident and Emergency Departments, HC 277
77 Department of Health and Department for Communities and Local Government (
81 National Audit Office, Emergency admissions to hospital: managing the demand, 31 October 2013, HC 739
82 Association of Directors of Adult Social Care ()
83 Local Government Association ()
84 LaingBuisson, Care of Older People—UK Market Report, 27th edition, 2015
86 Lancashire County Council ()
89 Registered Nursing Home Association ()
90 Humberside Independent Care Association (), Coverage Care Services (), Brendoncare Foundation (), Heritage Care Group ()
91 Kent Integrated Care Alliance (), Care Association Alliance (), Eden Futures ()
92 Kent Integrated Care Alliance (), Eden Futures ()
93 Q148, Humberside Independent Care Association ()
94 Q148, Eden Futures (), Home Group ()
95 Eden Futures (), United Response (), Camphill Village Trust (), Heritage Care Group (),
96 Care Association Alliance (), Camphill Village Trust ()
97 Brendoncare Foundation (), Heritage Care Group (), Eden Futures (), St Ronan’s Care Home ()
99 Association of Directors of Adult Social Care ()
100 Four Seasons Healthcare ()
102 Camphill Village Trust (), United Response (), Hft ()
103 Anthony Collins Solicitors Newsroom, , 16 November 2016 and Anthony Collins Solicitors Newsroom, , 20 February 2017
104 Care Quality Commission, The State of health care and adult social care in England 2015–16 (October 2016)
105 Lancashire Care Association ()
106 Kent Integrated Care Alliance ()
107 Care Association Alliance ()
108 Association of Directors of Adult Social Care ()
109 Lancashire County Council ()
110 Care Quality Commission, The State of health care and adult social care in England 2015–16 (October 2016)
112 Association of Directors of Adult Social Care ()
115 UK Homecare Association ()
117 Kent Integrated Care Alliance ()
118 Brunelcare ()
119 County Councils Network ()
121 United Response ()
123 Lancashire Care Association ()
124 HFT (), Lancashire Care Association (), Registered Nursing Home Association ()
128 Care Quality Commission, The State of health care and adult social care in England 2015–16 (October 2016)
129 Care Act 2014,
132 Department of Health, Care and support statutory guidance,
134 Norfolk County Council ()
135 Association of Directors of Adult Social Care South East Region (). See also West Berkshire County Council () and St Helens Council ()
136 Local Government Association ()
137 Lancashire County Council ()
138 County Councils Network ()
139 Surrey Care Association ()
140 Martha Trust ()
141 Surrey Care Association (), Lancashire Care Association ()
142 Jewish Care ()
143 Care England ()
144 Local Government Association ()
146 Heritage Care Group ()
147 Department of Health, Care and support statutory guidance,
148 , National Care Forum (), Humberside Independent Care Association ()
149 Care Association Alliance ()
151 Surrey Care Association (), Oxfordshire, Care England ()
152 Avenues Group ()
153 Surrey Care Association (). See also Humberside Independent Care Association ()
154 Martha Trust ()
155 Humberside Independent Care Association ()
156 Care Association Alliance ()
157 Registered Nursing Home Association ()
158 Avenues Group ()
159 Brunelcare ()
161 . See also Brunelcare ()
163 UK Homecare Association, (September 2015)
164 LaingBuisson, , Seventh Edition (2015–16)
166 Essex Independent Care Association ()
167 Lancashire Care Association ()
169 Brunelcare ()
170 Lancashire Care Association ()
171 Brunelcare (), Heritage Care ()
172 Lancashire Care Association (), , Brendoncare Foundation ()
174 Q324 [Heather Wakefield], Save Autism Services Haringey (), Care Association Alliance (), Brunelcare ()
175 Exalon Autonomy Group ()
179 Botton Village Families Group ()
180 Care Association Alliance (), Humberside Independent Care Association (), Kent Integrated Care Alliance (), Lancashire Care Association ()
182 Leicester City Council (), Isle of Wight Council () and Liverpool City Council ()
186 Skills for Care, The state of the adult social care sector and workforce in England (September 2016)
189 Skills for Care, The state of the adult social care sector and workforce in England (September 2016)
190 Skills for Care, The state of the adult social care sector and workforce in England (September 2016)
191 Skills for Care, The state of the adult social care sector and workforce in England (September 2016)
192 National Care Forum (), Oxfordshire Association of Care Providers (), Royal College of Nursing ()
193 Mandy Abbey (), Kent Integrated Care Alliance (),
197 . See also Mandy Abbey ()
198 Surrey Care Association (), Norfolk County Council (), Home of Comfort for Invalids (), North West Region Association of Directors of Adult Social Care ()
200 UNISON ()
201 UNISON ()
203 Voluntary Organisations Disability Group ()
204 Camphill Village Trust ()
205 See also
206 Kent Integrated Care Alliance ()
207 See also
209 Skills for Care, The state of the adult social care sector and workforce in England (September 2016)
211 UNISON ()
216 The Cavendish Review, An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings (July 2013)
218 Home Group (), Eden Futures ()
221 Skills for Care, The state of the adult social care sector and workforce in England (September 2016)
222 Guild Care ()
223 MHA ()
224 Care England ()
225 Guild Care ()
228 Skills for Care, The state of the adult social care sector and workforce in England (September 2016)
229 National Care Forum (),
230 Guild Care (), Lancashire Care Association ()
234 UNISON ()
240 See also
242 Carers UK ()
245 North West Region Association of Directors of Adult Social Care (). See also Norfolk County Council ()
247 Surrey Care Association ()
252 Liverpool City Council ()
254 Lancashire County Council ()
257 London Borough of Camden (), Bristol City Council (), Lancashire County Council (), St Helen’s Council ()
263 Independent Age ()
264 Brendoncare Foundation (), Jackie Luland ()
266 Independent Age ()
267 Alzheimer’s Society ()
269 Carers UK ()
270 Home of Comfort for Invalids ()
273 National Institute for Health Research School for Social Care Research, Overcoming barriers: Unpaid care and employment in England (undated)
277 Independent Age ()
29 March 2017