Conclusions and recommendations
1.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. (Paragraph 14)
2.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. 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. (Paragraph 16)
3.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. (Paragraph 27)
4.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. (Paragraph 33)
5.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. 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 (Paragraph 36)
6.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. (Paragraph 39)
7.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. (Paragraph 41)
8.The Government should take steps to resolve the uncertainty over paying for sleep in shifts 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. (Paragraph 46)
9.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. (Paragraph 50)
10.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. (Paragraph 51)
11.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. (Paragraph 52)
12.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. (Paragraph 54)
13.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. (Paragraph 56)
14.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. (Paragraph 63)
15.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. (Paragraph 68)
16.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. (Paragraph 73)
17.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. 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 (Paragraph 75)
18.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 (Paragraph 76)
19.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. (Paragraph 92)
20.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. (Paragraph 93)
21.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. (Paragraph 94)
22.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. (Paragraph 95)
23.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. (Paragraph 96)
24.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. (Paragraph 97)
25.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. (Paragraph 100)
26.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. (Paragraph 105)
27.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. (Paragraph 113)
28.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. (Paragraph 114)
29.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. (Paragraph 117)
30.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. (Paragraph 119)
Organisation of health and social care services
31.The Department for Communities and Local Government should review the operation of the Disabled Facilities Grant, and in particular the extent to which its administration and operation is hampered by the split in responsibility between district and county councils and between housing and social care departments in unitary authorities The evidence we received suggested that beneficiaries found the process slow and cumbersome, had little say in the adaptations and doubted that it was always good value for money. (Paragraph 124)
32.The Government should be more realistic in its expectations for integration. The time needed for such large scale changes to take place is significant and there is little evidence available yet on the benefits of integration, both in terms of patient outcomes and efficiency savings—the recent National Audit Office report on health and social care integration reflected this. Furthermore, progress, which is dependent on good local relationships between health and social care, varies across the country. (Paragraph 134)
33.There are various barriers to integration which the Government must address. These include organisational differences between the NHS and local government; different payment incentives; different regulatory, performance and outcome frameworks; information sharing; workforce challenges and lack of funding for social care. Lack of social care funding is undermining integration, with reduced budgets causing tension between local partners. (Paragraph 135)
34.The differences between the health and social care workforces in terms of culture, pay and conditions, career development and progression are stark. This presents a significant challenge to closer working, which is also inhibited in many local areas by difficulties in recruiting and retaining staff. The Government should acknowledge the challenge that this presents and with Skills for Care and Health Education England set out a strategy for aligning the two workforces. (Paragraph 136)
35.Place-based planning on health and social care which has had input from local politicians is more likely to take into account other local services, such as housing, benefits and public health, and therefore result in wider integration of services and better outcomes for the people who use them. Decisions on pooling health and social care budgets should be made locally. If this is not the case, there is a risk that local areas will not have the flexibility to use their budgets on local integration priorities and progress on integration will be impeded. Furthermore, we agree with Stephen Dorrell of the NHS Confederation that local government should be involved in the commissioning of local health services. This would further ensure that decisions about local health services are informed by the needs of the local population and the shape of existing local public services. (Paragraph 138)
36.STPs are an important opportunity for places to take a longer-term approach to integrating health, social and other local services and, therefore, to be a success, local government should be an equal partner in planning. The Government and NHS England should review the STP footprints with the aim of making them better aligned with local authority boundaries. (Paragraph 141)
37.Funding constraints and demographic pressures are acting as a driver for some councils to innovate and change the way they deliver care. However, due to budget pressures, most councils are in panic mode and are not ready to rethink the way they do things. The Government should create an innovation fund to encourage and give councils the capacity to consider how innovative approaches could be applied in their local area. (Paragraph 144)
38.Assistive technology is already helping people stay at home longer, reduce hospital admissions and coordinate care between different agencies, and smart technology will be an important part of improving care in the future. At the moment, however, very widespread use of digital technology is limited by the extent of broadband and 4G coverage. It also needs to be usable by and acceptable to service users and carers. (Paragraph 148)
39.Councils are also starting to use digital data platforms which, by drawing together data from different sources, helps them track individuals’ journeys through the health and social care system and target resources and commission more effectively. (Paragraph 149)
40.The Department of Health, NHS England and the Local Government Association should explore how best to bring together centrally and regularly update information on innovation in the delivery of health and social care in local areas. (Paragraph 150)
41.Shared Lives appears to be an exciting innovation which enables care provision within family and community relationships. The Government should commission a wide-scale evaluation on the outcomes and cost effectiveness of the scheme and, where appropriate, care commissioners should consider it as one of a range of available care options. (Paragraph 154)
42.We greatly sympathise with the families’ concerns, but are not well-placed to investigate or adjudicate the matter. But the amount of evidence we received on this one issue, and the strength of feeling expressed, exemplifies the reasons why it is essential to get the country’s social care system right in the short, medium and long terms. (Paragraph 155)
Future funding
43.We agree that local government should be allowed to use some of the additional business rates revenue, according to need, to close any adult social care funding shortfall that exists when 100% business rates retention comes into effect, before being allocated new responsibilities. (Paragraph 157)
44.Council tax and business rate income will not be commensurate with current and future local demand for adult social care. The Government should report on what measures it intends to use to tackle the disparity that this will create. We recommend that funding should be made available for adult social care via a central government grant linked to need and rising demand. As further insurance against future shortfalls in funding, the Government should consider giving local authorities greater flexibility on the level at which they set council tax. (Paragraph 159)
45.Expenditure on adult social care will need to rise as a proportion of total public expenditure. (Paragraph 161)
46.After successive attempts at reform and in the context of ever-increasing demographic pressures on the system, the need to find a way to fund social care for the long-term has now become urgent. The solution needs to be implemented in the next spending round. (Paragraph 163)
47.It is vital that political parties across the spectrum, together with the social care sector and the wider public, are involved in the process of reaching a solution. The importance of this was demonstrated by our visit to Germany, where decisions on reforming social care funding were supported by a political consensus, trades unions and employers and therefore attracted wide public backing. As a first step, political parties should agree to work together. (Paragraph 166)
48.There then needs to be an open debate about where the money to fund social care should come from. The review must consider taking funding from a wide range of sources, including:
1. Hypothecating national taxation (income tax, National Insurance Contributions, asset taxes, inheritance tax) and, in particular, the feasibility of introducing compulsory social insurance, publicly owned and administrated, on the German or Japanese model.
2. All age-related expenditure (the state pension, including the triple lock pension guarantee, winter fuel allowance, concessionary bus fares, free prescriptions and, indirectly, TV licences).
Although they are likely to remain an important part of funding adult social care, local taxes, which will not grow at the same rate as need, cannot be the main funding solution. We have already called for significant reforms to council tax in our report on fiscal devolution in the last parliament and reiterated these in the report we published last year, Devolution: the next five years and beyond. (Paragraph 167)
49.As well as considering future sources of funding for social care, the review should also take into account the range of uses for which social care funding is required. Over the course of this inquiry, we have identified these as including:
- Care and support, including:
- Meeting people’s needs for care and support;
- Preventative care and early intervention; and
- Assessments for carers, leading to the provision of support for carers.
- Payment of fees to providers, which contribute to:
- The wages of the care workforce, as well as holiday, sickness, pension and travel costs;
- Their training, qualifications and career development, including measures to enhance the status of the care workforce;
- Meeting providers’ business costs and generating profit to invest in their capital assets and the workforce. (Paragraph 168)
50.The review will also need to consider whether to go ahead with implementation of Phase Two of the Care Act 2014, as well as, more broadly, whether people should be means tested and, if so, how they should contribute to the costs of their care. As part of this, it should also consider the different approaches to including the value of a person’s home in the means test for residential and home care. (Paragraph 169)
51.While health care will remain free at the point of use, social care will remain needs- and means-tested. We note the challenge that this lack of alignment in entitlements to health and social care poses to integration. (Paragraph 170)
52.We are conscious that in many places in this report we have called on the Government to provide more funds for social care. We have not done so lightly. The Parliamentary Under-Secretary of State for Community Health and Care did not agree that the social care system was in crisis—a term the Chief Executive of NHS England was happy to use—preferring to describe it as ‘under stress’. But it is clear from our inquiry that unless significant extra funds are provided in the short and medium terms, the social care system will be unable to cope with the demands placed upon it. Extra funding alone will not solve the problems that face us, but without it the other steps we have suggested will quite simply fail. (Paragraph 171)
53.We welcome the Government’s announcement of a Green Paper on the long-term funding of social care later this year. We reiterate that, to ensure the work results in a lasting solution, it should be taken forward on a cross-party basis. We will review the scope of the Green Paper when it is published later this year and consider whether a further inquiry into any issues it raises is needed. (Paragraph 172)
29 March 2017