The adult social care workforce in England Contents

1Funding and oversight of the care sector

1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care, the Ministry of Housing, Communities & Local Government, Skills for Care and the Association of Directors of Adult Social Services.1

2.The Department of Health and Social Care (the Department) is responsible for adult social care policy. One of the nine priorities in its Shared Delivery Plan: 2015 to 2020 is to make sure the health and care system workforce has the right skills and the right number of staff in the most appropriate settings to provide consistently safe and high quality care.2 The Care Act 2014 places a duty on local authorities to ensure that there is diversity and quality in the market of care providers so that there are enough high-quality services for people to choose from.3 The adult social care workforce in England comprises around 1.5 million workers across more than 20,000 organisations. Turnover and vacancy rates across the care workforce are high. Care providers have difficulty recruiting and retaining workers, particularly to the roles of care worker, registered manager and nurse. Demographic trends suggest that demand for care will continue to increase and people’s care needs will continue to become more complex.4

3.In December 2017, Health Education England and Skills for Care began consulting on a new strategy for the health and care workforce, the first to cover the care workforce since the Department’s previous strategy published in 2009.5 The Government has also promised a Green Paper by July 2018 on the future funding of adult social care for older adults.6 In parallel, it is developing proposals for the future of care for working-age adults with care needs.7 The Department claims that the Green Paper on funding of care for older people, due by summer 2018 will address the financial pressure on care services.8

Delivering care while local authorities are under financial pressure

4.In 2016–17, local authorities spent around £15 billion commissioning care, mostly from independent (private and voluntary) providers. Between 2010–11 and 2016–17, spending on care by local authorities reduced by 5.3% in real terms.9 Despite this, the Department told us that the adult social care sector is currently adequately funded, as they consider that all local authorities with care responsibilities, with the possible exception of Northamptonshire County Council, are fulfilling their statutory duties under the Care Act 2014, to provide care to adults with substantial and critical needs.10 The Department told us that the majority of local authorities are halfway through four-year funding settlements, which the Department believes provides them with greater certainty over funding and helps them to budget more effectively.11 Over this period, local authorities have also received several ad hoc funding increases to meet demand for care services.12 The Ministry of Housing, Communities & Local Government told us that it had given local authorities access to an extra £9.4 billion of funding over the Spending Review period, but that this is coming from various sources including council tax rises and the social care precept levied by local authorities on their council tax payers.13 The government has not yet confirmed spending for the period after the current Spending Review settlement expires, so, for example, the social care precept and increases to the Better Care Fund may not be permanent.14 The Ministry of Housing, Communities & Local Government told us that it monitored whether local authorities were spending the additional money on adult social care, and that they had been to date.15 However, the Department acknowledged that the sector is under significant financial pressure and requires more investment.16

5.Local authorities spend most of the money allocated to care on commissioning care home placements and homecare. Self-funders, people who pay for their own care, are currently subsiding people whose care is paid for by their local authority. They pay, on average, 41% more for care home placements than local authorities do. The Department told us that some of this difference will be reasonable, as local authorities can pay less through block contracts with providers, but the Department agreed that to some extent self-funders do subsidise local authority placements.17 In November 2017, the Competition and Markets Authority (CMA) published a report into the care homes market, and concluded that the current model of service provision cannot be sustained without additional public funding, and that significant reforms are needed to enable the sector to grow to meet the expected substantial increase in care needs.18 The Department confirmed that it would be responding to the report in early March 2018.19 The Government’s response, published after our evidence session, largely accepted the CMA’s findings, but noted that the beneficial impact of additional investment made in the March 2017 budget may not have been fully realised in the CMA’s analysis.20

6.The Department advises local authorities, through its guidance to the Care Act 2014, to have regard to the sector’s benchmark costs for commissioning homecare. However, over four-fifths of local authorities pay below this benchmark cost.21 The Department told us that they did not accept this figure as a national benchmark cost for care, as local markets are different and local authorities should each determine their own pay rates for care. The Department does not have their own set of benchmark costs, so it has no way of knowing whether local authorities, either individually or collectively, are paying enough for homecare.22

7.Levels of unmet need are high and rising.23 The Association of Directors of Adult Social Services (ADASS) told us that most unmet need relates to people with low to moderate care needs. Most older people with low to moderate needs no longer receive publicly funded care as their needs are not considered to be substantial or critical. Few local authorities now have the funds to provide services to people with low to moderate care needs, despite the long-term preventative benefit this could bring.24 Only 27% of councils have arrangements in place to monitor unmet need.25 The Department accepted that the total number of people receiving publicly funded care had fallen, as a result of local authorities focusing on meeting their statutory responsibilities.26 The Department confirmed it does not monitor how much local authorities spend on discretionary services, as opposed to statutory services.27

8.The Department said they have learned much from the CMA’s analysis of the care home market. However, the Department’s only suggestions for how providers could become more efficient was by increasing the use of technology to save on back-office costs. The Department sees itself as having a role in the promotion of innovation in this sector and technological innovation, but accepts that technology has been underused to date.28

The Department’s responsibilities as national steward of the care market

9.Around two–thirds of providers’ income comes from taxpayers via local authorities.29 The Department confirmed it has overarching responsibility for the care market.30 The Department acknowledged that it had not yet developed the right strategy for a care system that meets the population’s current needs. The Department also commented that there are a series of issues, such as integrating health and social care, which had been known about for decades but not addressed by successive governments.31 The Department acknowledged that, compared with the health service, it has fewer levers to influence social care. The Department is not seeking additional powers, but will consider how it can use its existing powers more effectively.32

10.The Department noted that under the Care Act there is a duty for local authorities to oversee their local markets.33 ADASS told us that local authorities are finding it challenging to fulfil these duties and their market position statements, which should explain what care services and support there are in a local area and shape the local market, are a relatively new innovation. Some local authorities do not yet have the staff with capabilities and capacity to undertake market oversight.34

11.ADASS also told us that there are local areas where commissioning of care is poorly coordinated by health bodies and local authorities and in some areas the local authority and the NHS have bid against each for care home placements.35 The Department accepted that there were particular problems with discharging patients from hospital on a weekend, for which it did not yet have an answer. The Department indicated that such problems can result from the unavailability of either social care or health services.36

12.The Department confirmed that there is no oversight or inspection regime of local authorities’ commissioning functions. This is different to health where the CQC inspects health commissioning. The Department has commissioned the CQC to undertake local system reviews, which are taking a holistic assessment of the provision of health and care services in 20 local authority areas, including commissioning of care. The Department said that valuable learning is coming from this programme. However, the reviews are currently focussed on 20 areas where people were experiencing challenges moving between health and social care services. The Department is considering whether to expand the programme. However, it believes local discretion over the commissioning of care is the right approach, as different areas have different requirements. It does not intend to impose a national system for commissioning and providing care.37

13.The Department cautioned that local authorities are locally democratically accountable, so there is a limit to the extent that the Department and its national partners can intervene. It also referred to the role of the Local Government Association in providing support to the sector, with funding from the Ministry of Housing, Communities and Local Government. The Department committed to looking at how it oversees and engages with local authorities.38

Immigration policy after UK’s exit from the European Union

14.There is wide regional variation across England in the number of care workers from the European Union (EU), with London and southern England having the highest proportions of EU workers.39 The Department told us that, to date, there has not been a decline in the number of people from the EU working in care.40 The next set of statistics on starters and leavers from the EU is due in the summer, and the Department will closely scrutinise this information. The Department said that the potential impact of Brexit is at the top of its agenda, and is considering workforce issues as one of its four biggest EU workstreams.41

15.The Department agreed that people from outside the UK are an extremely important part of the care workforce, and that their contributions are hugely valued.42 We raised the concern that it is not just future immigration policy that is relevant, but the ‘welcome’ that workers from the EU experience when they come to the UK.43 The Department recognised that the UK’s departure from the EU could have a large impact on the care workforce. The Department cautioned about guessing what the UK’s future immigration policy will be, and its potential effects on the care sector. It confirmed that it is working with the Home Office to ensure the needs of the care sector are taken into account as future immigration policy is developed.44

1 C&AG’s Report, The adult social care workforce in England, Session 2017–19, HC 714, 8 February 2018

2 C&AG’s Report, para 4

3 Q 35

4 C&AG’s Report, paras 2–5, 10, 15, 17

5 C&AG’s Report, para 18

6 Qq 154–155

7 Q 121

8 Qq 28, 34–35, 64, 109–114, 156, 185–186

9 C&AG’s Report, paras 2, 20

10 Qq 28, 63, 100, 170–174

11 Qq 157–59

12 Q 133