Health and Care Bill

Written evidence submitted by the British Association of Social Workers (HCB59)

Written evidence: Health and Care Bill

Introduction

1. The British Association of Social Workers (BASW) is the professional association for social work in the UK with offices in England, Northern Ireland, Scotland , and Wales. With over 22,000 members we exist to promote the best possible social work services for all people who may need them, while also securing the well-being of social workers working in all health and social care settings.

2. S ince The Government first introduced its Health and Care White Paper to the House of Commons on 11 February 2021, BASW England has been consulting its members on the proposals and the implications of any forthcoming Bill for social workers.

3. In response to this BASW England published two policy statements relating to the Bill as well as, specifically, the Hospital discharge proposals. [1] [2]

4. Our consultation with members ranged from discussion and policy position development with the BASW England Adult group as well as through an online member survey and two engagement events. This engagement was important to inform social workers about the contents of the Bill, which had by then passed second reading, as well as to ensure the voice of members and those with lived experiences was heard and echoed throughout our response.

5. Our online survey garnered just 16 responses, although we were pleased that our two member engagement sessions we hosted online were both well attended, thus helping us gain a wide understanding of the views of social workers.

6. Through this engagement we were also able to identify the key issues and proposals in the Bill that were most pertinent to the needs and concerns of social workers. We also think it is important to remember that the Bill does not contain proposals for long-term social care reform, something that will have a major impact on social workers and the wider health and care sector.

Key themes of interest

7. As mentioned, BASW England members has focused its response to the proposals within the Bill on key specific areas of interest. The areas we identified were as follows:

· Integration

· Discharge to assess

· Digital and data

· Quality assurance

8. This written evidence will incorporate both the collective view agreed by the BASW England Adult group which ha s been set out in previous policy statements , as well as provide a direct account of members who have agreed to share their thoughts with us on the Health and Care Bill proposals either through our engagement events or through our online survey.

Integration

9. The Health and Care White Paper builds on recommendations made to the government by NHS England for the statutory recognition of current Integrated Care Systems (ICS). These were developed across most of the country as Sustainability and Transformation Partnerships (STP), effectively collaboration partnerships between hospitals, community health and local authorities.

10. BASW England has a unique insight through our members where we can ensure the voice and perspective of social work is represented and heard on issues like integration of services in health and social care. There are many settings where social workers are already working closely with health agencies, including mental health trusts, hospital discharge teams as well as GP practices. Social workers have frontline experience of partnership working and can provide insight into the challenges faced with integration of services as well as how we think it can best work.

BASW England supports the principles underpinning integration working in equal partnership when it comes to social care and our health services. However, we retain concerns around assimilation: where social work is co-located with health but the arrangements that support a partnership model with accountability and governance and joined up systems and services in are not in place. We support a model of integration that recognises the unique contribution of social work and the social model of care.

11. We would want to ensure that social workers maintain an independent professional structure and identity, and that the values and contribution of social work will not be lost or diluted in anyway. This would need to be clearly reflected in the governance and structure of integrated arrangements, with a shared purpose to achieve parity of esteem across funding, workforce, leadership, and decision-making arrangements.

Meeting health and social care needs in an integrated way

12. BASW England believes that there are substantial benefits for people, families and communities with integration and collaborative working. The perspective of social work and its articulation of social care needs, how best to meet them and their relationship with health care needs, has an essential role to play in achieving these benefits.

13. The positive outcomes that can be achieved through health and social care integration relies on a more holistic approach to meeting needs. Integrating social workers and their management structures with the NHS will give added weight to the perspectives of other non-medical professions (currently known as allied health professions) and contribute to improving people’s wellbeing in a more multi-disciplinary way, particularly in relation to hospital discharge.

14. There have been recent developments in the way that people with complex health and social care needs are discharged from acute settings in hospital, that many in adult social care are concerned

about. Previously an assessment of social care needs took place before discharge, whereas now the NHS funds services to facilitate discharge and the assessment takes place post-discharge. There are good intentions behind this by ensuring the safe discharge into familiar environments which thus leads to more appropriate evaluations, and there also are cost-effectiveness benefits for health budgets. But the way that this change has been applied has led to concerns about the overriding of individual’s rights and the opportunity to be listened to, heard, and involved in making decisions about care and treatment, and overriding some of the principles of the Care Act (2014) and the Mental Capacity Act (2005). In a nutshell some people are being provided with services that mitigate against them achieving a degree of independence and thus a greater cost to the public purse in the long run. This is being addressed, but it may have been avoided if an integrated service with integrated assessment and meeting of health / social care needs was in place, and there were integrated budgets so that the long-term costs were properly evaluated. Parity and equity of long term sustainable funding for social care as well as NHS investment will be integral for social care and health to be fully integrated.

Social Care Reform

15. BASW England believes that many of the key challenges faced in social care would not automatically be solved by integration with health. Integration must be seen in the context of proposals for social care reform.

16. BASW England have long been calling for reform to social care that goes beyond addressing the injustices of social care funding. Supporting people to be as independent as possible should be the focus, and in achieving this people also need greater certainty about whether their needs will be met and more transparency about how decisions are made.

17. Our view on the debate on the cap on care costs and free personal care is that the same high standard of social care should be provided to individuals regardless of their socio-economic status i.e., whether they are eligible for public funding.

Challenges

18. We have reservations about a headlong dash to create fully integrated health and social care structures. The cultural and knowledge basis of health and social care are different. BASW England needs to be satisfied that the social model, which is crucial for the future of health care as well as social care, could be lost.

19. The independence of the social work perspective in health settings is incredibly valuable. The freedom to challenge, without fear of organisational censure, is an excellent foil to the power of health organisations. It would be detrimental to all for this to be eroded and independence, which we see as a strength, be undermined.

BASW England member engagement

20. A key issue that was raised as part of our engagement related to membership of the proposed Integrated Care Boards (ICB).

21. We asked members as part of our online survey the following: "Do you think people and families with lived experience of health and social care services should be appointed as ICB members?"

· Yes 14

· No 0

· No answer 2

Some of the written responses to the survey from our members included:

"There needs to be strong social work/care representation to ensure the values of self-determination and personalisation are implemented."

"My concern about LA representation is who will this be?? There are very few Directors of Adults Services who are SW's; many come from housing/commissioning etc. Therefore, I would argue that they have a lack of understanding of the practical workings of adults legislation. There should be a qualified social worker on the board, perhaps Health Watch also, service user voice too."

"I feel it is important to have a social worker on the ICB boards in order to ensure that someone can promote the Care Act and ensure that processes and procedures do not impact on a service-users rights and also promotes a 'home first' approach'."

We also asked members for their thoughts on integrated care system.

Strengths:

"A larger footprint may allow for more specialist services to be commissioned where single CCGs may have struggled to do this previously."

"Good partnership working starts with good strategic partnerships."

"Enables frontline collaboration for benefit of people using services".

Weaknesses:

"No local accountability Too centralised so unable to be flexible to specific local circumstances Too dominated by the agenda of acute health care so fails to understand the needs of people with lifelong health and care needs such as people with learning disabilities, autistic people or people in mental health crisis."

"Lack of voice for service users and their families and it’s clearly a medical model!"

"They need to work more closely with workers on the ground to know where the problems lie and develop co-ordinated responses"

What good looks like:

"Person centred with clear accountability to local people via the LA lead member and local self advocacy groups"

"Being able to smoothly arrange funding so people with lived experience are not compromised. Joint systems. Regular meetings"

"Identifying the strengths and weaknesses in both the health and social care systems and finding joint ways to address them. Moving away from any blame culture that exist."

Hospital Discharge

22. The Care Act 2014 presently outlines a clear responsibility of local authorities to work together with health partners to bring people to the centre of any decisions made, with the Wellbeing Principle forming a corner stone of the assessment process and provisioning of support and services. We have concerns that a local authority’s Care Act duty to integrate care and support provision with health provision to promote individual wellbeing may be compromised. The proposals for Discharge to Assess do little to promote Article 8 and 5 of the Human Rights Act or offer assurances as to how rights will be upheld. These were key concerns reported with the current Discharge to assess arrangements implemented during the Covid-19 pandemic.

23. Echoing the findings of the Healthwatch and British Red Cross survey in October 2020 [3] , BASW England presently has several concerns about the experiences shared by people, the support available, safety and consistency in approach to those with eligible needs for care and support leaving acute care settings, based on this proposed consolidation of Discharge to Assess pathways. Clear accountability needs to be established within this process to ensure an individual’s rights and the opportunity to be listened to, heard, and involved in making decisions about care and treatment, are fundamental principles of this proposal in line with the principles of the Mental Capacity Act (2005 [4] ) and the right to respect for private and family life   ( Article 8). This article protects people’s autonomy and well-being which includes participating in decisions about care and treatment, setting discharge and recovery goals, the protection for people from psychological trauma or physical harm caused by premature or delayed discharge which can lead to serious distress or hinder recovery. [5]  

24. Appropriate resourcing in terms of staff and services must be available to ensure individuals receive the right service at the right time that is appropriate to their needs.

25. A survey of Social Workers conducted in December 2020 involved in hospital discharges highlighted that the vital contribution of social work in the multidisciplinary team was being marginalised by the medicalisation of people’s journeys out of hospital. Most importantly, social workers felt that the voice of the individual was lost, indicating arrangements being made without consent or against people’s views and wishes. Social workers identified that the care and support arranged for people’s hospital discharge was often more restrictive e.g., not being supported to return home with care or equipment but being taken to a care home. The survey highlighted an increase in the number of people being discharged to 24-hour care settings, with restricted access to family, networks, and existing care resources. A key concern raised by social workers was the loss or reduction of the involvement of social workers skill set in hospital discharge and the ability to effect change at crucial decision-making points.

26. BASW is calling for clarity of the hospital discharge responsibility, accountability and funding from the 30th September 2021 the end date of the current guidance to end. [6] In addition, what this journey will look like for people, as well as security for the social care sector through these multiple transition points.

27. BASW England does not support the proposed Discharge to Assess formula as proposed in the Bill, for the following reasons:

· Arrangements for people are being made without their consent.

· A lack of clarity over whether individuals will have the opportunity to discuss their feelings and thus be able to make their own decisions is not clear currently.

· Our members concern about the application of and adherence to the Mental Capacity Act and the Human Rights Act leading to the erosion of people’s human rights.

· Loss of social work skills, role, identity, and the value of social work’s contribution.

· Lack of assurance about how Core principles of the Care Act including the responsibility of local authorities to work together with health partners to bring people to the centre of any decisions made and the Wellbeing Principle will apply to hospital discharge.

· Absence of the social model of care and support which looks beyond a person’s medical needs focussing on the barriers to independence ensuring the person gets the right support at the right time to maintain their independence, choice, and control.

· Concerns about the availability of adequate community resources.

· A lack of clarity about the review of the Discharge to Assess model which was due to take place on the 31st of March 2021. To date there has been no formal evaluation of this approach and therefore it is unclear how it will transition under the proposed legislation.

BASW England member engagement

28. We asked members as part of our online survey the following: Are you supportive of the Discharge to Assess policy and model of hospital discharge?

Yes 2

No 12

No answer 2

Some of the written responses to the survey from our members included:

"People were place in DTA placements sometimes without consultation with families and far from home. Some didn’t want to move to DTA placements, but this was ignored and they were moved into them, then were there for months as Social Care couldn't get out to see them."

"DTA provides a neat solution for moving people out of acute hospital beds quickly, but ignores the Human Rights of a person, by denying them the opportunity for support to return home promptly."

"It creates dependency and increases pressure on an already woefully under resourced local authority provision. DTA during covid, separated families, sometimes permanently. It felt very much as though older people, who were largely victims of the policy, had less rights than anyone else."

Note: DTA/D2A refers to Discharge to assess

Quality Assurance of Local Authorities Adult Social Care by the Care Quality Commission

29. BASW England believes that the scope of the Care Quality Commission’s "new duty" needs to be extended further to include, not just the power to assess delivery of services, but to include assessment and care planning. Eligibility determination and deciding on what will and will not be funded (personal budgets) should be a key focus of the CQC.

30. BASW England does, however, support the principles of oversight and transparency. However, any such system must put people’s lived experiences at the heart and the voicers of people using services needs to be heard.

31. BASW England also believes it is crucial that we will have the opportunity to make our case during the process of detailed system design and practice, in line with the Department’s pledge to work "with government partners and the sector".

32. There remains concern about the CQC as an organisation and its ability to understand social care as well as a deeper knowledge that will be needed.

Member engagement

33. We asked our members as part of our online survey the following: In principle would you support what is proposed?

Yes 5

No 6

No answer 4

Data sharing and collaboration

34. As many commentators from the social care sector will no doubt be pointing out, the "health benefits" can also be considered as social care benefits. What follows are additional gaps in the data that we think should be included, and endorsement of the collecting of data on self-funders.

Unmet need:

· Local authorities do not record the needs of people they deem to be ineligible or the extent to which people are under-supported in the system. Anecdotally, there is a widening gap between unmet needs and service provision but within the current system of data collection there is no way of knowing what the funding gap is.

· Under the Care Act, Local Authorities have a power to meet non-eligible needs, and the duty to record all needs identified by the assessment. They must provide written information and advice to individuals to assist them in preventing, reducing, and delaying needs that have been determined as non-eligible. However, what is missing is the requirement to quantify, record and report on unmet or under-met need.

· In the Ten Reforms for Social Care, reform 6 articulates BASW England groups’ position on unmet need (see appendix).

35. We think that local authorities should collect data on needs that have been determined as ineligible and that this should be published locally and nationally.

36. Self-funders:

· Self-funders are not state funded but who pay for social care from their own resources.

· There are currently no requirements to include information collected about self-funders in official statistics, making it problematic to estimate the size of the population.

· The data about people who self-fund their care is limited and based on estimates, the accuracy is therefore in question. There are differences in how data is collected across local authorities and by care providers. This leaves a substantial gap in knowledge and understanding about who needs social care, how care is funded and the impact that this has on the adult social care system.

· The lack of information gathering and reporting about self-funders means that adult social care profiling and decision making about budgets at a local, regional, and national level are based upon incomplete data.

37. Proposals:

Within the new proposals in the Health and Care Bill relating to the use of data and digital BASW England is keen to ensure that the issues of data collection, recording and publishing in relation to unmet and under-met will be addressed alongside the need for data about people who self-fund their care. Both are missing but necessary pieces of the jigsaw in making sense of the landscape in adult social care funding, resources, and provision.

Member engagement

38. Members shared the following comments on the proposals for data sharing and collaboration:

"In my locality our social care systems don’t speak to health systems so having to duplicate information. Working from health information may not capture the social care figures as we’re still very much separate."

"Another piece of bureaucracy that is time consuming to complete and takes people away from delivering care."

"Spend too much time focusing on data quality and data integrity while not really understanding what the data says or being able to accurately interpret the ambiguity"

END OF FORMAL SUBMISSION

APPENDIX

‘ten reforms we would like to see in social care’

The need for social care reform has had a rising profile this year, sadly because of the impact of Covid-19. The Prime Minister has reiterated his promise to fix "the injustice of social-care funding", and the possibility of this being translated into policy received a boost with the recent publication of the Parliamentary Health and Social Care Committee inquiry into social care funding and workforce.

Commenting on this report, a Guardian editorial in October said the pandemic has exposed the " unfairness, confusion and humiliation felt by people using the system" https://www.theguardian.com/commentisfree/2020/oct/25/the-guardian-view-on-the-social-care-crisis-fix-a-broken-system . This editorial was prompted by the Parliamentary Health and Social Care Committee calling for investment in the social care sector of £7bn a year by 2023-24, the introduction of a lifetime cap to protect against catastrophic care costs and endorsing "further consideration" of free personal care. The report also called for improvements to the pay and recognition given to social care workers

But will these measures alone fix the what is described by politicians on all sides and the media, as the ‘crisis in social care’? The answer from most social workers will be a resounding no.

The BASW England Adults Group has been discussing social care reform since the announcement in 2018 that a Green Paper on Adult Social Care would be published. Many of the ideas that have been developed were outlined in the BASW England submission to the Parliamentary Health and Social Care Committee.

What follows outlines what has been agreed by BASW England about how social care should be reformed, but the debate continues and the BASW England Adults Group wants your views.

1. Widen the scope of reform to include assessment of need

There was no reference to social work in the report the Parliamentary Health and Social Care Committee , despite the BASW England submission emphasising that "social workers have a key role to play in decisions about how people access and receive social care".

To some extent this omission is understandable because of the focus on funding. But the report nevertheless painted a picture of individuals having to struggle by themselves to find social care without support, reinforcing the current narrative whereby social care is something that just needs to be accessed and there is no recognition of the role of assessment and care planning. It’s like talking about the NHS and ignoring the role of GPs.

We need to establish social work more firmly into policy agenda. None of what follows can be achieved without this.

2. Establish a clearer statutory mandate for professional judgement

We would like the reforms to develop a clearer specification of professional judgement within the overall local authority decision-making process. Local authorities have a statutory duty to make decisions about individual social care needs, the extent to which they meet the Care Act eligibility criteria and how these are going to be met from public funds. Social work professional judgements are a core element of this.

We would like to see a clear distinction in the decision about how much money is required to meet an individual’s needs, between the professional judgment of the social worker about how needs can be most effectively met and how resource constraints are taken into account .

3. Greater transparency

Whatever system of funding is adopted, we think it should aim to improve the ability of individuals to exercise control over how their health and social care needs are met. One of the principles that was to underpin the development of the Green Paper that was proposed in 2018, was that of "Control", which was described as follows: "What matters to individuals and families is the ability to direct the care they receive and autonomy to lead the lives they want".

It is essential that there is citizen control, choice and greater certainty and transparency in the way that the system operates. We propose that the framework provided by the Care and Support Statutory Guidance be revised to achieve greater transparency in assessment of need and financial decision making.

4. Place more emphasis on supporting people to have greater independence

This is important not only as an equality principle, but as a means of preventing, reducing and delaying the development of needs. For people that have life-long support needs, the focus should be on supporting independence and well-being, with support built around the person.

We recommend the Care Act is amended to incorporate the United Nations Convention on the Rights of Disabled Persons concept of independent living i.e. "the equal right of all persons with disabilities to live in the community, with choices equal to others".

5. Better prevention

The Care Act made significant advances in enshrining a preventative approach, but the funding arrangements did not give it the pre-eminence it requires. Also the relationship between needs that can be prevented, reduced or delayed and eligibility, is convoluted and confusing.

Rehabilitation has been facilitated by making local authority reablement services free, and there have been significant developments by social workers in applying a strengths-based approach to prevention, but there is still insufficient emphasis on the benefits of prevention both for individual health and social care outcomes and costs.

There is widespread agreement that there is not enough meeting of low-level needs that can prevent further needs developing, because of what LGA has described as the "eligibility driven approach".

We believe that the way eligibility is determined should be revised to incorporate prevention more explicitly and transparently with Health, Local Authorities and partners developing a Place Prevention strategy with associated central government costs for implementation.

6. Recording of unmet need

The report of the Parliamentary Health and Social Care Committee stated: "unmet need i s frequently raised as a major problem in social care". Age UK have undertaken some research and estimate 1.4 million adults have unmet needs.

The Parliamentary Health and Social Care Committee went on to state that "local authorities now restrict funding for social care to those with the most severe needs, meaning that individuals who might previously have been eligible for Government-funded care now either have to self-fund, rely on family, or go without".

Local authorities should collect data on needs that have been determined as ineligible and this information should be published locally and nationally.

7. Increase the number of social work posts

There is widespread recognition that significant investment in social care is required to reverse the detrimental impact of austerity. But the narrative is about responding to increasing need arising from demographic changes, through increased funding for service provision.

We want to see long term investment and sustainable funding to address the impact of the pandemic and many years of austerity that have resulted in :-

· reductions in staffing relative to demand, increasing caseloads and risk

· increased stress and consequent ill-health

· Postcode lottery for citizens

· National variation of thresholds and access to services

· Gatekeeping of finite resources

8. Enhancing the role of social care workers

As well as calling for improvements to the pay and conditions of social care workers, the Parliamentary Health and Social Care Committee report proposes the streamlining of "the training of social care workers in order to improve routes of entry to the profession and improve career progression for existing social care workers". BASW England supports this but it is of concern that no reference is made to career progression into social work. Instead the focus is on developing "proposals to improve alignment with training for NHS staff and to improve the professional recognition of social care staff".

9. No more Care Act "easement"

Some of the changes brought about by the Coronavirus Act have intended to simplify how needs are met. There is a case for some of these changes to be adopted permanently, but in our view this is not the case for the Care Act easements guidance. Any proposal that elements of this guidance be incorporated into the Care and Support Statutory Guidelines, is a reform that BASW England would oppose.

Our concern is the Care Act easements guidance significantly reduced transparency in local authority decision-making in determining what needs will be met. Whilst this an understandable consequence of emergency powers (that have now ceased), it is not acceptable in the longer term and would be a backward step if ever enacted again.

10. Social care should be available to all regardless of socio-economic status

The debate about social care funding reform will inevitably focus on introducing a cap on care costs and free personal care. BASW England will strongly be advocating for equality standards, the same high standard of care should be provided to individuals whether or not they are eligible for public funding.

We will also closely scrutinise proposals for free personal care to guard against a dilution of the Care Act duty to meet eligible needs. Our concern is that people may have to wait for funding to become available to meet needs that are not related to personal care and deemed less urgent.

CONCLUSION

Reforms have to produce greater certainty about how care and support needs will be met, both for those people who currently have needs and for those of us who may have needs in the future. This will take more than just reforming the social care funding system, people need also need more certainty about whether or not their needs will be met and more transparency about how decisions are made.

BASW England will continue to represent the voices of our members and lobby parliament to ensure social care reform addresses our priorities as outlined in this response..

September 2021


[1] https://www.basw.co.uk/media/news/2021/jul/basw-england-policy-response-health-and-social-care-bill

[2] https://www.basw.co.uk/media/news/2021/jul/health-and-social-care-bill-%E2%80%93-hospital-discharge-proposals-basw-england-response

[3] https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20201026%20Peoples%20experiences%20of%20leaving%20hospital%20during%20COVID-19_0.pdf

[4] MCA principles

[5] https://www.bihr.org.uk/coronavirus-hospital-discharge

[6]

[6] 6. https://www.gov.uk/government/publications/hospital-discharge-service-policy-and-operating-model/hospital-discharge-service-policy-and-operating-model

 

Prepared 15th September 2021