Conclusions and recommendations
1.Adults who receive social care paid for by their local authority are not yet getting the support they need consistently in order to get the most out of personalising their care. Personalising care means trying new, different and, therefore, potentially risky ways to meet users’ needs, otherwise they will not experience any benefit over conventional care services. Users need providers and local authorities to support them to do this, managing the risk that unconventional and untried approaches might lead to their needs not being met. Some groups of users are more capable of trying new approaches to care, for example younger adults with physical disabilities who have been leading the way with personalisation for over 20 years. However, other groups of users are likely to need greater support to personalise their care: older adults, those in residential care, those with learning disabilities and those who lack mental capacity. Across all user groups, those who choose to receive a direct payment to employ personal assistants need support to undertake their responsibilities as employers. The Department of Health (the Department) and partner bodies, such as Skills for Care, have done some work in this area, including the provision of good practice guidance, and found that not all local authorities are providing adequate support.
Recommendation: The Department should ensure that published good practice for local authorities and providers shows what high-quality and proportionate support looks like, how much it costs and that it meets the diverse needs of users.
2.Some people with personal budgets may not be receiving care that is genuinely personalised. From April 2015, the Care Act 2014 requires that all users receive personal budgets. However, the Department does not believe that everyone counted by local authorities as having a personal budget does actually have genuine choice and control over the services they receive. In particular, it considers that some local authority areas who reported that 100% users had personal budgets in 2014–15 may be over-stating the position; being less rigorous than other areas in the definition they use of what constitutes a personal budget. Choice and control can also be limited by local authorities’ responses to financial pressures and the Comptroller and Auditor General has reported previously that these pressures on are limiting personalisation for some users. The Department is also concerned that in some areas not enough people are being supported to take their personal budgets as direct payments or individual service funds, which research shows can result in better experiences for users.
Recommendation: The Department should explain in its response to this report how it is going to test that all users are receiving genuinely personalised services and that users are receiving the form of personal budget that is most appropriate to their individual circumstances.
3.It is not yet clear how local authorities can implement personal budgets to maximise benefits to users and more evidence is needed. There is agreement across the social care sector that personalisation, through personal budgets, is the right way forward and that well-implemented, personalised services benefit users and result in better outcomes. England is leading the world in personalising social care but this means that we are breaking new ground. There is, therefore, a clear need for ongoing research and evaluation to identify successful new ways of working, thorough analysis of how these benefit users and rapid sharing of what works. The Department is already committed to improving its analysis of its existing data about user outcomes. The sector is still not gathering and sharing enough evidence on what are the best ways to personalise care services to maximise the benefits to users.
Recommendation: The Department, with partner organisations, should carry out further analysis of existing data from the Adult Social Care Survey as well as improving the POET survey and its take-up, to improve evidence and understanding of both how personal budgets are used and how they lead to better outcomes for users. In its response to this report, the Department should make clear its criteria and timeframe for assessing the success of personal budgets.
4.We share the concerns of local authorities that funding cuts and wage pressures will make it hard to fulfil their Care Act obligations. Local authorities must save money at the same time as demand for social care rises. The Department acknowledges that local authorities need to find savings from their adult social care budgets and that, inevitably, this means seeking savings through personalised care. It contends that the Spending Review process considered the affordability of social care, which led to additional funding for local authorities to deliver adult social care through the 2% council tax precept and extra funding within the Better Care Fund. We consider this to be a complacent response as the amount different local areas can raise through the 2% precept will vary depending on the areas’ existing levels of council tax. The Nuffield Trust, the Health Foundation and the King’s Fund estimate that there is likely to be an adult social care funding gap of between £2 billion and £2.7 billion by 2019–20, even taking into account the additional funding. The Local Government Association predicts an even worse funding gap of £4.3 billion by 2020. The recent introduction of the national living wage has increased costs for care providers. The Department acknowledges that it needs to test whether the Care Act requirement for local authorities to review users’ care arrangements annually may be too rigid and therefore an unnecessary cost for local authorities. The Department is obliged to review the impact of policy changes and amend if it finds they are unnecessarily burdensome or support authorities to meet new burdens.
Recommendation: The Department should improve its knowledge and understanding of the impact of funding reductions on the adult social care sector. It should send its review of the impact of the National Living Wage to us by November 2016 and report to us by then on the results of its review of the Care Act, including the current requirement on local authorities to review users’ care arrangements annually.
5.The fragility of the social care market in many areas is putting people at risk. There is a real threat that many care providers will not survive. Local authorities have a statutory responsibility to ensure that there is a sustainable local care market and a diversity of providers. There are indications that the sustainability of the care market in some areas is at risk: many providers are not sure they can continue to operate as fees from local authorities drop, wage increases come into force and as they experience difficulties recruiting and retaining enough suitably qualified staff. Small and medium-sized providers, essential to promoting a diverse range of provision to give users greater choice of services, are particularly vulnerable to adverse market conditions. The Department is particularly concerned that young adults with learning disabilities do not have access to a sufficient range of meaningful activities. The Department has what it calls a ‘stewardship’ role in managing the care market and workforce at the national level but it has not yet defined or communicated what the extent of that role is and it is still working out what information and guidance to provide to local authorities to support them in their market-shaping role.
Recommendation: The Department should be realistic about its remit as national steward of the social care market and its resources to carry out this role. It should publish its National Market Position Statement before the summer recess, through which it should clarify:
- what being the ‘national steward’ of the social care market means in practice;
- how it will assess the impact of funding cuts and restrictions on care providers;
- its role in workforce management;
- how it will promote social care as a valued career and enable career pathways through social care and health; and
- under what circumstances it would take action to support the care market, and in what way.
6.The health sector faces an even greater challenge in rolling out personal health budgets and integrated health and social care budgets than the social care sector did in rolling out personal budgets in social care. There are significant barriers to implementing personal health budgets and integrated health and social care budgets. Many health staff are risk averse, to minimise clinical risks to users. They can find it difficult to support users to try novel and potentially risky ways to meet health needs. Integrating health and social care budgets requires local authorities and health bodies to overcome the issue that healthcare is free whereas social care is means-tested. The Department does not consider designing and measuring joint health and social care user outcomes to be feasible.
Recommendation: The Department should put in place a robust regime to monitor the effectiveness of personal health budgets and of integrated health and social care budgets as it rolls them out, applying relevant lessons from the rolling out of adult social care personal budgets.
7.There is a strong link between people’s wellbeing and the quality of their housing but too many people with care needs are living in unsuitable housing. Many older adults with care needs are living in housing that is no longer appropriate for them, and supported housing is particularly important for some adults with high care needs. The Department is concerned that changes to Local Housing Allowance will put additional pressure on social care provision, and that not enough supported housing is being built. The Department has confirmed that it is involved with the Department for Communities and Local Government and the Department for Work and Pensions in the review of Local Housing Allowance. The Department for Communities and Local Government told us that it is examining how supported housing should be funded and supported.
Recommendation: The Department of Health and the Department for Communities and Local Government should jointly write to us setting out how housing policy supports people with care needs and how they will monitor local authorities’ progress with making housing and care work together.
8.Many users with complex and long-term care needs receive money and benefits from several different sources, which is confusing for them and potentially an inefficient way to support people. Adults with care and support needs are often in contact with the benefits system, for example, receiving Personal Independence Payments or Disability Living Allowance. Some social care users will also be receiving support funded by the health service. It is not easy for users to understand a system where their money comes from several different sources, nor are we convinced that this is an efficient way to fund people’s needs.
Recommendation: The Department should write to us in a year setting out the progress made in ensuring that people who qualify for different pots of money for similar or overlapping purposes can spend it in a way which represents good value for money. We would also like to know from the Department how the different bodies issuing the payments are working jointly to provide a clearer, more efficient process.
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2 June 2016