Reforming adult social care in England

This is a House of Commons Committee report, with recommendations to government. The Government has two months to respond.

Twenty-Second Report of Session 2023–24

Author: Committee of Public Accounts

Related inquiry: Reforming adult social care in England

Date Published: 20 March 2024

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Adult social care includes social work, personal care and practical support for adults with a physical disability, a learning disability, or physical or mental illness, as well as support for their carers. Family or friends provide most care unpaid. The Department of Health and Social Care (the Department) is responsible for setting national policy and the legal framework. The Department for Levelling Up, Housing and Communities (DLUHC) oversees the distribution of funding to local government and the financial framework within which local authorities operate. The Care Quality Commission (CQC) regulates registered care providers for quality, and since April 2023 has responsibility for assessing how well local authorities are meeting their duties under the Care Act. State funded care is funded by local authorities, who coordinate with local health systems through Integrated Care Systems (ICSs). In 2022–23, local authorities supported more than one million people with care needs, at a cost of £23.7 billion. As at Autumn 2023, there were 470,476 people awaiting an assessment of their needs, care or direct payments to begin or for a review of their care plan. Most local authority care is commissioned from nearly 18,000 independent providers, who also provide care to people who arrange and pay for their care privately, as local authority support is means-tested. The sector employs around 1.6 million people and as at March 2023 there were 152,000 vacancies (9.9% vacancy rate), with the number of jobs in care expected to increase in future years.

In 2021, the Department published a white paper setting out a 10-year vision for adult social care. Government committed £5.4 billion funding to reform the sector including £3.6 billion to introduce changes to the way people pay for care (charging reform) and £1.7 billion for wider reform to the system (system reform). In 2022 the Department reprioritised some of this funding to help ease immediate pressures, including delaying charging reform by two years to October 2025. In April 2023, government published revised plans for system reform, which scaled back its short-term plans to £729 million over the period 2022–23 to 2024–25.

Conclusions and recommendations

1. It is far from clear if Integrated Care Systems are making a demonstratable difference to adult social care delivery. We remain concerned about under-representation of adult social care in health-dominated systems and are deeply sceptical about the feasibility of integrating health and care when they are funded so differently. Despite the Department’s assurances of “colossal improvement” on data and on how well the system is working, we see no clear strategy for pulling together data from across the sector and making it accessible. The public does not yet have access to data to see how care outcomes in their local area compare nationally or to other areas in the way they could with Primary Care Trusts. Time will tell whether Care Quality Commission (CQC) inspections of local authorities and ICSs will enable greater insight across public services. While inspection may give CQC and the Department an aggregate picture, Parliament and the wider public may not enjoy the same transparency.

Recommendation 1: In its Treasury Minute response, the Department should set out what is doing to:

  • bring together its performance and inspection data relating to adult social care (from Integrated Care Systems and other sources); and
  • ensure that these data are accessible, publicly available and enable people to i) assess whether patients are getting better outcomes in their areas and ii) allow the public to make comparisons between different areas.

2. We remain unconvinced as to whether the Department knows if it is achieving value for money from the additional funding going to adult social care. Recent funding for adult social care includes short-term, top-up pots of money in response to crises. In response to emerging pressures in 2022, government awarded £1.6 billion to help speed up hospital discharge through the Better Care Fund and £1.1 billion new grant funding to local authorities through the Market Sustainability and Improvement Fund (MSIF). It is troubling that, though MSIF funding is intended to support “tangible improvements” in adult social care, the Department did not quantify by how much the funding has contributed to its three objectives of increased staff pay, increased fee rates paid to providers or reduced waiting times. It remains to be seen whether the new CQC inspection regime, and promised improvements in local commissioning, can provide better assurance that top-up funding is not simply going into provider profits. We are concerned that the Department’s grasp of what it is getting for the £1.6 billion funding to support hospital discharge, is similarly vague. Although ‘supported discharges’ (the number of people being discharged from hospital with a package of care) may well have increased as a result of this funding, it is far from clear whether this represented good value compared with other interventions.

Recommendation 2: The Department should write to the Committee alongside its Treasury Minute response to set out how it is assuring itself that each additional fund aimed at supporting adult social care is achieving value for money, including on benefits in relation to costs, for example:

  • how much additional capacity it has bought with the discharge funding through the Better Care Fund.
  • how it will ascertain whether funding for market sustainability and improvement has not just ended up increasing provider profit margins.

3. Local authorities are having to plan and commission adult social care services against a backdrop of fragmented and uncertain funding. We have long voiced our frustration at the short-term and multiple funding pots provided to local government and recommended that government explore ways to provide more confidence over long-term funding. We note that funding announced for adult social care in 2022 covered 2023–24 and 2024–25, yet we remain concerned at the perpetual late announcement of overall funding for local government. We welcome the additional funding for adult social care in recent years but recognise these are short-term top-ups, often designed to be spent on specific initiatives (such as increasing pay to providers) with no guarantee that they will continue. The latest government announcement of an additional £500 million for adult and children’s social care is welcome but comes just weeks before the next financial year is due to begin and may be too little, too late to have a demonstrable impact. Patchwork funding and short-notice announcements hinder the sector’s ability to plan for the long-term and risks undermining delivery of the Department’s 10-year vision for adult social care. Funding for adult social care, including supporting the planned reforms, for 2025–26 onwards will depend on the next spending review.

Recommendation 3: Given it has a 10-year vision for reforming adult social care, in its Treasury Minute response, the Department should set out:

i) what it is doing now to prepare for the next spending review and make the case for more stable funding, and

ii) what it can do to give local authorities greater certainty over funding and allow them to plan for the longer term.

4. Notwithstanding its recent efforts to make adult social care a more attractive career, the Department has still not produced a convincing plan to address the chronic staff shortages in the long-term. Workforce vacancies in adult social remain worryingly high with some places, such as rural areas, particularly affected. In 2022–23, workforce vacancies exceeded 152,000 (9.9% vacancy rate) despite overseas recruitment of 70,000 staff. Proposed visa restrictions and risks of exploitation raise significant questions about the Department’s reliance on overseas staff in future. Given these significant challenges and numerous, repeated calls for a workforce strategy, we find the white paper’s coverage of the workforce woefully insufficient to the scale of the task. It does not tackle all the significant factors impacting recruitment and retention. For example, there is scant detail on pay. Neither does the white paper provide detail on workforce plans beyond 2025 despite the Department’s forecasts that the number of adult social care jobs will grow by almost one-third by 2035. Once again, we see one approach for the NHS and another for adult social care. While we welcome the Department’s plans to professionalise the workforce, it falls short on providing leadership on pay and ensuring parity of esteem with equivalent NHS roles.

Recommendation 4: In the absence of an NHS style workforce plan, alongside its Treasury Minute response, the Department should write to the Committee setting out how it will lead the sector to identify and address workforce challenges, including:

  • achieving a sustained reduction in the number of vacancies in the sector (beyond 2025)
  • addressing the challenges and risks associated with international recruitment
  • tackling local variations in vacancy rates
  • addressing issues around disparity with NHS pay
  • assessing which workforce initiatives are most effective for recruiting and retaining staff.

5. Long-awaited workforce reforms are way behind schedule and too dependent on a ‘novel’ payment system. We welcome the Department’s launch of the care workforce pathway, which aims to provide consistent career progression for those working in the sector, but we are concerned at the lack of progress on other workforce reforms. At £265 million, they make up the largest budget in the scaled-back system reform portfolio (£729 million). It is alarming that many workforce projects are behind schedule because they depend on delivery of a bespoke payments system to pay suppliers directly. These include the Department’s project to increase the number of regulated professionals and the £136 million flagship project to improve workforce training, originally planned for September 2023. Although the Department assures us that its decision to build a bespoke system was well-evidenced, this ‘difficult’, ‘complex’ and ‘novel’ project is creating a worrying bottleneck and the Department acknowledges that the target date of summer 2024 is already at risk.

Recommendation 5: The Department should in its Treasury Minute response to this report:

  • confirm which of the workforce reform projects depend on this payments system and update us on progress with each; and
  • update the Committee on progress with the payments system (including any updates to the RAG rating and implementation date) and when it expects the workforce initiatives that depend on it to start to have an impact.

6. The Department faces significant challenges in delivering its ‘vision’ for adult social care reform, and Parliament and the sector must be able to hold it to account for its progress. It is worrying that the Department has no roadmap for achieving its 10-year vision for adult social care, or any targets or milestones beyond 2025. Though we agree that some flexibility to adapt as the Department learns has merit, there is currently nothing meaningful in place to demonstrate progress towards targets. With charging reform postponed, system reform scaled back and limited progress from the Department even on its reduced ambition for system reform, we cannot help but be sceptical as to whether the vision is still achievable. The Department has given us little assurance that charging reform, delayed to October 2025, can be delivered on schedule; work will need to start soon but funding for it will depend on the next spending review. We are encouraged that the Department says it is monitoring local authorities’ capacity to deliver charging reform alongside system reform and other departmental initiatives but somewhat concerned that it is not yet sequencing activity to alleviate pressure.

Recommendation 6: The Department should set out a roadmap for delivering its vision, pulling together all its reform activity (system reform and charging reform), and the risks to delivery with key performance indicators and should publish six-monthly updates on progress to time and budget.

1 Funding and delivery structures for adult social care

1. On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department) and from the Department for Levelling Up, Housing and Communities (DLUHC) about progress in reforming adult social care in England.1

2. Adult social care covers social work, personal care and practical support for adults with a physical disability, a learning disability, or physical or mental illness, as well as support for their carers. In 2022–23, local authorities in England spent £23.7 billion on adult social care, supporting more than one million people with care needs. Local authority-funded care is means-tested, with support only provided to those with less than £23,250 in savings. Many more people self-fund their care or receive support from unpaid carers. Around 18,000 independent care providers, including private, not-for-profit and voluntary organisations, deliver most paid care. In 2022–23 around 1.6 million people (5.8% of the country’s workforce) were working in adult social care.2

3. The Department sets national policy, agrees central government funding, and is accountable to Parliament and the public for the performance of the care system as a whole. DLUHC is responsible for the financial framework within which local authorities operate and distributes funding to local authorities via the Local Government Finance Settlement (LGFS). Local authorities assess people’s care needs and fund care and support for those who are eligible, in line with their statutory duties under the Care Act 2014. In 2023–24 there are 153 local authorities in England who commission publicly funded social care. The Care Quality Commission (CQC) regulates almost 15,000 registered care providers in England for quality and assesses the financial sustainability of around 60 potentially ‘difficult-to-replace’ providers. From April 2023 it has new responsibilities to assess how well local authorities meet their duties under Part 1 of the Care Act.3

4. In 2019, the government promised to “fix the crisis in social care”. In September 2021 it committed £5.4 billion funding over three years to reform adult social care, on top of existing budgets. Of this, at least £3.6 billion was to change the way people pay for care (charging reform) and £1.7 billion was for improvements to the wider adult social care system (system reform). In its December 2021 white paper, People at the Heart of Care, the Department set out its 10-year vision for transforming social care in England and gave more detail on its proposals for system reform.4 The Department has since altered its reform plans, delaying charging reform from October 2023 to October 2025, and scaling back short-term system reform plans, reducing the budget from £1.7 billion to just £729 million for 2022–23 to 2024–25, as at October 2023. In total, £1.01 billion of system funding has been reallocated to other adult social care priorities. In April 2023 the Department published its updated plans for system reform in a policy paper, Next steps to put People at the Heart of Care. This maintained planned spending on digital reforms and unpaid carers, but reduced commitments on housing and workforce reforms.5

Whether Integrated Care Systems are making a difference

5. Introduced under the Health and Care Act 2022, Integrated Care Systems (ICSs) aim to bring NHS and local government services together, to improve services and health outcomes for people in their area.6 As we have previously reported, ICSs have the potential to improve the health of the populations they serve by better joining up services and focussing more on longer-term actions and preventative measures to address the causes of ill-health.7 The Department rejected our previous recommendation to publish guidance for ICSs on supporting systems to resolve joint working issues. It considered that the structures and processes in the Health and Social Care Act 2022 ensure different partners support each other to overcome differences in funding and accountability arrangements.8

6. High quality social care can keep people independent, healthy, and out of hospital. Although some NHS and social care funding is pooled through the Better Care Fund, the two sectors maintain separate budgets. Among other fundamental differences, the NHS is funded nationally and is free at the point of use, while social care is funded locally and access is means tested. We asked how the Department could ensure that integration delivered the benefits intended when the two sectors are funded so differently. The Department told us it accepted the difficulties of managing across different structures as a fact of life. We heard that one of the reasons for creating ICSs was to create a vehicle where the NHS and its partners could manage resources, take joint decisions and, in some cases, pool budgets. Dialogue between the two had “never been better”, according to the Department, and the model was driving better coordination and cooperation, though it acknowledged this was anecdotal.9

7. When we pointed out that it was not always the case that social care got the right weighting in ICS structures because they are health-led, the Department acknowledged that the system was not working everywhere.10 The National Care Forum called for the appointment of adult social care leads on all Integrated Care Boards (statutory bodies that are responsible for planning and funding most NHS services in an area) to correct the tendency for everything to be viewed solely through a healthcare lens, noting that the voice of adult social care providers and people accessing care and support was often overlooked.11 Likewise, the County Councils Network (CCN) expressed its concerns that the structure of ICSs meant that key decision-making powers lay with the NHS, and that local government had limited representation on Integrated Care Boards. This, explained the CCN, meant that although joint decision-making can take place, it is not guaranteed that monies distributed by these means will always be allocated to social care. CCN also queried whether Integrated Care Board officials really understood how joint funding should be spent and the risk that it might be absorbed into spending on acute health pressures.12

8. We asked the Department about how it was measuring the effectiveness of joint working between health and social care in delivering better outcomes for the people they served. We heard that CQC inspections, which were now measuring systems as well as institutions, and a “colossal improvement” in data gave the Department a lot more information than it had had before the COVID-19 pandemic. For example, the Department told us that the metrics it was tracking around the number of care packages and hospital discharge, such as how many discharged patients returned to hospital within 90 days, were the real key performance indicators (KPIs) on how the system was working.13 We shared our concerns that there seemed to be no strategy for pulling together these data and KPIs from across the sector and then publishing it and making it accessible. The Department insisted that CQC inspection was providing transparency and that it published a lot of data.14 We acknowledged that there may be more data published and that aggregate data may be available to the Department and to CQC. However, we challenged on how easy it was for members of the public or MPs to understand this data and use it to compare their area with another comparable area, as it had been with Primary Care Trusts.15 The Department provided written evidence after the session to explain the data it publishes on outcomes for ICSs. However very few, if any, of these metrics directly relate to social care, and it is not clear if ICS performance against these metrics is published. The Department also highlighted that there are specific metrics for integrated care in the Better Care Fund Policy Framework 2023–25, but these are only used to set “ambitions” for local systems, without an assessment of whether or not they were achieved.16

Additional funding for adult social care

9. In recent years, there have been multiple short-term, top-up funding announcements for adult social care in response to crises. In response to emerging pressures in 2022, in the November 2022 Autumn Statement government announced funding of up to £7.5 billion over two years (up to £2.8 billion in 2023–24 and up to £4.7 billion in 2024–25) to help stabilise the care sector. This included £2.7 billion of new grant funding: £1.6 billion through the existing Better Care Fund to support hospital discharge and £1.1 billion to local authorities through a new Market Sustainability and Improvement Fund (MSIF) for local authorities to support “tangible improvements” in adult social care.17 Further top-up funding during 2023 included £570 million for the Market Sustainability and Improvement Workforce Fund, and £30 million for urgent and emergency care, announced in July, with a further £10 million top-up for urgent and emergency care announced in September.18

10. When we asked what the Autumn Statement funding had delivered, the Department told us it had achieved “an awful lot” but acknowledged this was not as much as it had wanted and there was more to come. The Department did not quantify how much the MSIF funding had contributed to its three objectives of increased staff pay, increased fee rates paid to providers, or reduced waiting times.19 The Department told us that 85% of local authorities had said they planned to use the money on fee rates and that “a lot” of local authorities had said that average fee rates had gone up by 8.9%, noting that this was above inflation. We heard that, as 70% of care provider spending goes on the workforce, this was a way of putting money into the workforce.20 Yet some care providers were more sceptical about the effectiveness of this top-up funding especially with further increases in the national living wage to come. For example, Care England reported that 84% of care providers said that government funding measures such as MSIF had had ‘no impact’ on their financial sustainability in 2023.21 Bupa Global & UK said that when engaging with local authorities it had become apparent that much of the Market Sustainability and Improvement Workforce Fund, which has similar requirements to MSIF, had been absorbed into central local authority costs, rather than being passed on to providers.22 The Local Government Association noted that much of the additional funding would go on meeting pay and inflationary pressures due to the sector’s higher exposure to costs associated with pay, energy, food and fuel prices.23

11. We asked about the risk of profiteering and how the Department was ensuring that the money it was putting into the system was going to the right places. The Department explained that was mainly down to the quality of commissioning and that, as CQC was now inspecting local authority commissioning, it would be getting an overview of how good that commissioning is. DLUHC told us that local authorities were responsible for ensuring that their local markets are working functionally and that they can continue to commission care. The Department pointed out that, as shown in the NAO’s report, provider profits were falling, and said it did not therefore consider there to be a particular risk of providers “creaming off profits”. It said that profits in social care were to be made more on the self-funder side than on local government funded care.24

12. With regard to additional funding for hospital discharge—£600 million in 2023–24 and £1 billion in 2024–25—the Department told us that delayed discharges had been consistently lower over the last 6 months than the previous year despite an increase in emergency admissions. The Department said that the best measure of whether money had been well spent was “supported discharges” – the number of people being discharged with a package of social care or community care. We heard that supported discharges were 17% higher at the end of December 2023 than December 2022.25 In written evidence, Mencap cautioned that one-off discharge funds like this do not tackle the systemic funding issues facing social care.26

13. Other evidence we received put forward alternative ways of taking pressure off the NHS and other parts of the public sector, that might offer better value for money. For example, the National Care Forum suggested that measures to enable a shift towards prevention and early intervention, rather than a narrower focus on hospital discharge of older adults to deal with NHS backlogs, could unlock benefits for people of all ages and a range of conditions and life situations.27 The Challenging Behaviour Foundation suggested that better community provision for people with learning difficulties could prevent unnecessary admission to NHS funded inpatient units and speed up discharge of people with learning difficulties.28

14. We noted that reform funding, including the £300 million budget to integrate housing into local and care strategies, had been redirected to support the system and asked what the consequences of that reprioritisation had been.29 Both the Department and DLUHC acknowledged the redirection of money from supported housing, and the Department told us that taking out the budget to integrate housing had been a ministerial decision. DLUHC went on to highlight the close cross-departmental working on housing; investment in affordable housing, which, it explained, would also benefit supported housing; and legislation designed to improve supported housing oversight.30

Fragmented and uncertain funding

15. We have reported before on the prevalence of short-term, one-off funding for local authorities and recommended that government explore ways to provide greater confidence over long-term funding.31 With regard to adult social care, this lack of financial certainty has constrained local authorities’ and providers’ ability to plan for the longer term, and caused investment in areas such as staff training, new accommodation and technological innovation to suffer.32 Local authorities have continued to report financial pressures and last year just under one-fifth of directors responsible for social care reported they were not confident they could meet their statutory duties for care in 2024–25.33 The Association of Directors of Adult Social Services (ADASS) reported that one-year funding settlements for local government, supplemented by short-term and targeted grant funding for adult social care, meant that the conditions and certainty have not been there for councils or providers to embark on multi-year investment programmes to fundamentally transform the services they offer.34

16. We asked about the local government finance settlement for 2024–25, noting that the longer the settlement is delayed, the more difficult it is for local authorities to prepare their budgets. DLUHC told us that in 2022 it had set out a policy statement that outlined not only the settlement for 2023–24 but also the outlines and main grants for 2024–25. The draft local government settlement for 2024–25 was, however, only published in full in December 2023, and did not include any provision for the update in the minimum wage announced in the autumn statement.35 A £600 million increase to this settlement, including £500 million for adult and children’s social care, was announced during our evidence session, but the final settlement was not confirmed until early February 2024.36

17. We challenged the Department on whether we were ever going to see a multi-year funding settlement for local government and if the extra money for adult social care in 2023–24 and 2024–25 would continue into future years. Both the Department and DLUHC acknowledged the benefits of multi-year funding but also the potential downsides if circumstances are volatile, such as high inflation. The Department told us that this would be a matter for the next spending review, of which the timing was not yet known, and decisions government takes, but that the Department would cope with whether it was a multi-year settlement or a one-year rollover.37

2 Delivering adult social care reforms

Planning for long-term workforce needs

18. We have repeatedly raised concerns about care workforce shortages. When we reported in 2018, vacancy rates for 2016–17 were 6.6%.38 The vacancy rate has increased since then and, as the NAO reported, in 2022–23 vacancies were 152,000, a rate of 9.9%, despite the recruitment of 70,000 staff from overseas. We observed that, although this was lower than the high point of 2021–22, when reported vacancies reached 164,000, this was still way off the 60,000 from 2012–13.39 The Department agreed that vacancies were too high but assured us that things were improving. We heard that monthly figures for November 2023 showed a vacancy rate of 8.4% but the Department acknowledged that these were not as robust as the annual figures.40 When we highlighted regional variation, the Department agreed that rural areas were undoubtedly worse affected and that addressing geographical disparities was a high priority for both its staff and local authorities. The Department noted the challenge that as more young people live in cities and more elderly people live in rural and coastal areas, demand was higher in rural areas but the people to deliver care were in the cities.41

19. In its 2021 white paper, the Department said it expected the number of jobs in adult social care to increase by almost one-third by 2035.42 Given its reliance on overseas workers to date, we asked what percentage of the workforce it expected to come from overseas in future. The Department told us that it did not do workforce planning in this way because it was not a public sector workforce but rather a private sector workforce with 18,000 employers.43 We asked whether recent changes in Home Office visa policies that restrict overseas workers from bringing dependents might have an impact on the sector’s ability to recruit from overseas. The Department assured us that it expected to be able to carry on recruiting internationally for people without dependents.44 We also asked about the risks of exploitation and modern slavery through the care sector. For example, the charity Unseen UK reported that its anti-modern slavery and exploitation helpline had seen a 606% increase in care sector cases from 2021 to 2022, and that it expected cases in 2023 to exceed 130. The Department told us that, while it does not have a statutory responsibility for the issue, it recognises the concern, and that it was working with other organisations to minimise the issue.45

20. Given the significant workforce challenges facing the sector, we asked the Department why it had not produced a workforce strategy, despite repeated calls from the sector and our previous recommendations.46 It told us that it considered the workforce chapter of its white paper to be its workforce strategy, and that it would not be possible to create a strategy similar to that produced for the NHS, as the Department is not the employer of the adult social care workforce.47 The chapter did not set out any detail on plans beyond 2025 and in our view is more a series of high level statements and aspirations.48 We heard from some in the sector, such as Bupa Global & UK, that, while they recognised the importance of creating improved career pathways for the adult social care workforce, the white paper fell short of addressing other key factors affecting recruitment and retention.49 The Nuffield Trust, in written evidence, said the white paper’s efforts “did not amount to a long-term strategy” and described the failure to address low pay as “striking”. It said that its research into workforce reform in other countries identified unintended consequences when moving towards greater recognition and professionalisation without accompanied pay increases.50 Although we acknowledged we were not expecting an NHS-style workforce strategy for social care, we noted that saying “there is a chapter” was “a bit of a cop-out”. We asked where the impetus to professionalise the workforce would come from if the Department did not take the lead. The Department explained that it was professionalising the workforce through its workforce reforms and cited its recent announcements on a career structure for the social care workforce and accredited care certificates, as examples.51

21. Care England said there was a widespread sense within the sector that careers in adult social care did not enjoy parity of esteem with the NHS and care workers were not afforded the same level of respect from the Government or across wider society.52 Pay for equivalent roles in adult social care is also lower than in the NHS and Community Integrated Care has reported that it could take more than 20 years before the pay gap is closed.53

Delivering workforce reforms

22. We welcomed the Department’s introduction of a new framework aimed at providing consistent career progression for the social care workforce (the Care Workforce Pathway) in January this year.54 However, we challenged the Department on why it had made so little progress overall on its workforce reforms which, even after scaling back, make up £265 million of the £729 million remaining for system reform.55 The Department told us that nearly all the budget goes on training and explained that these training initiatives were, in turn, dependent on the development of a bespoke new payments platform to pay suppliers directly.56 This includes the £136 million project for improving workforce training and development, originally planned for launch in September 2023, and the project to increase the number of regulated professionals, against which there was zero spend in 2022–23.57

23. The Department explained that it had chosen a new payments system because it would be making payments on a scale not dealt with before and had wanted a proper way to guard against fraud risk, and assess and process requests that came in.58 We challenged the Department on why it had not simply routed payments through local authorities, given they have good existing connections to providers. The Department told us that not all providers had relationships with local authorities which, it said, had been a problem during the pandemic for getting money directly to providers. It assured us that the business case would have looked at all the different options and that having a direct route to providers had “an efficiency to it” and would provide an option to do that in future, should it be needed.59 In written evidence provided after the session the Department confirmed that it had selected a new digital platform by the NHS Business Services Authority as the preferred option in part because local authorities did not have direct relationships with all care providers in their areas. Other reasons cited were to avoid the potential for inconsistencies in approach to training and distribution of funding, and to make it easier to collect data on the value for money of the training.60

24. When asked when the payments system would be ready, the Department told us that it was aiming for summer 2024 but that delivery was “at risk”. The Department described the system as “difficult”, “complex” and “novel” which, we noted, sent “chills down our spine”.61 The Department has since confirmed that the payments system is rated ‘amber’, meaning that successful delivery is feasible but there are still significant issues that the Department is addressing.62

Assessing progress with reforms

25. The NAO reported that the 2021 white paper set a 10-year ‘vision’ for transforming adult social care, but that the Department had no long-term funded plan for achieving it and no milestones beyond the end of the current Spending Review period, March 2025. In addition, it was difficult to understand whether system reform was on track from the Department’s portfolio reporting.63 With charging reform postponed, system reform scaled back and limited progress on the revised ambition for system reform, we challenged the Department about the achievability of the timeline and where it was in terms of progress towards that vision given how much had changed.64 The Department told us that is had not yet achieved as much as it wanted, but said it had not changed any of its 10-year ambitions.65 We heard that having a long-term vision but being flexible about how it achieved that vision was the right approach because the Department was learning a lot about the system through improvements in data and wanted to be able to change its plans based on what it was learning.66

26. We challenged the Department on how it was applying lessons from its earlier attempt at charging reform to meet the revised implementation date of October 2025. The Department told us that charging reform was “not a delivery challenge; it was a money challenge”, and that was why it delayed it and redirected the money from charging reform into the system. The Department assured us it had been ready to deliver, and it had learned a lot from the six trailblazer local authorities. It told us about the innovative ways that the trailblazers had discovered to get through more care needs assessments, for example, using online digital technology and having different mixes of teams rather than relying on a social worker. We heard that one of the trailblazers made a 40% productivity improvement through those approaches.67 As the NAO’s report pointed out, to achieve the revised timetable, work would need to begin soon yet the funding set aside for charging reform has been diverted elsewhere and the levy to support it dropped.68 When we asked about how it would fund charging reform, the Department told us that the funding and the timetable for the next spending review were questions for the next spending review.69

27. We asked the Department and DLUHC what they were doing to ensure that local authorities could deliver charging reform alongside system reform, with all the other pressures on them. The Department told us one of the reasons for delaying charging reform had been local authority capacity given other pressures on them and that, before giving a new chunk of complicated work alongside all the other things they had to do, it would want to be sure they could do it well.70 DLUHC told us that it was working closely with local authorities to ensure they had capacity do all the critical things going through them, including reforms to children’s services which it said was also a major system reform. We heard that all these programmes were at different stages of development and that DLUHC was working with local authorities to make progress on things like quality and productivity but was not currently sequencing reforms with local authorities to address local pressures and priorities.71

Formal minutes

Monday 11 March 2024

Members present

Dame Meg Hillier, in the Chair

Paula Barker

Olivia Blake

Sir Geoffrey Clifton-Brown

Peter Grant

Sarah Olney

Reforming adult social care in England

Draft Report (Reforming Adult Social Care in England), proposed by the Chair, brought up and read.

Ordered, That the draft Report be read a second time, paragraph by paragraph.

Paragraphs 1 to 27 read and agreed to.

Summary agreed to.

Introduction agreed to.

Conclusions and recommendations agreed to.

Resolved, That the Report be the Twenty-second Report of the Committee to the House.

Ordered, That the Chair make the Report to the House.

Ordered, That embargoed copies of the Report be made available (Standing Order No. 134).


Adjourned till Wednesday 13 March at 1.00 p.m.


The following witnesses gave evidence. Transcripts can be viewed on the inquiry publications page of the Committee’s website.

Wednesday 24 January 2024

Sir Chris Wormald KCB, Permanent Secretary, Department for Health and Social Care; Michelle Dyson, Director General for Adult Social Care, Department for Health and Social Care; Catherine Frances, Director General for Local Government, Resilience and Communities, Department for Levelling Up, Housing and CommunitiesQ1–115

Published written evidence

The following written evidence was received and can be viewed on the inquiry publications page of the Committee’s website.

RSE numbers are generated by the evidence processing system and so may not be complete.

1 ADASS (The Association of Directors of Adult Social Services) (RSE0013)

2 Age UK (RSE0030)

3 Alzheimer’s Society (RSE0012)

4 Association for Real Change (RSE0001)

5 Bupa Global & UK (RSE0023)

6 Care England (RSE0003)

7 Care Quality Commission (RSE0026)

8 Centre for Care – University of Sheffield (RSE0019)

9 Community Integrated Care (RSE0007)

10 Healthwatch England (RSE0020)

11 Homecare Association Ltd (RSE0015)

12 Local Government Association (RSE0027)

13 MHA (Methodist Homes) (RSE0010)

14 Mencap (RSE0005)

15 Mental Health Matters (RSE0018)

16 National Care Forum (RSE0004)

17 National Housing Federation (RSE0016)

18 Nuffield Trust (RSE0024)

19 Rethink Mental Illness (RSE0022)

20 Rochdale Borough Council (RSE0029)

21 Sense (RSE0011)

22 Stein, Tony (CEO, Healthcare Management Solutions) (RSE0028)

23 The British Association of Social Workers (BASW) (RSE0032)

24 The Challenging Behaviour Foundation (RSE0014)

25 The Chartered Institute of Public Finance and Accountancy (CIPFA) (RSE0008)

26 The County Councils Network (CCN) (RSE0031)

27 Unseen (RSE0021)

28 Voyage Care Ltd (RSE0017)

29 Women’s Budget Group (RSE0006)

List of Reports from the Committee during the current Parliament

All publications from the Committee are available on the publications page of the Committee’s website.

Session 2023–24





The New Hospital Programme

HC 77


The condition of school buildings

HC 78


Revising health assessments for disability benefits

HC 79


The Department for Work & Pensions Annual Report and Accounts 2022–23

HC 290


Government’s programme of waste reforms

HC 333


Competition in public procurement

HC 385


Resilience to flooding

HC 71


Improving Defence Inventory Management

HC 66


Whole of Government Accounts 2020–21

HC 65


HS2 and Euston

HC 67


Reducing the harm from illegal drugs

HC 72


Cross-government working

HC 75


Preparedness for online safety regulation

HC 73


Homes for Ukraine

HC 69


Managing government borrowing

HC 74


HMRC performance in 2022–23

HC 76


Cabinet Office functional savings

HC 423


Excess Votes 2022–23

HC 589


MoD Equipment Plan 2023–2033

HC 451


Monitoring and responding to companies in distress

HC 425


Levelling up funding to local government

HC 424

Session 2022–23





Department for Business, Energy & Industrial Strategy Annual Report and Accounts 2020–21

HC 59


Lessons from implementing IR35 reforms

HC 60


The future of the Advanced Gas-cooled Reactors

HC 118


Use of evaluation and modelling in government

HC 254


Local economic growth

HC 252


Department of Health and Social Care 2020–21 Annual Report and Accounts

HC 253


Armoured Vehicles: the Ajax programme

HC 259


Financial sustainability of the higher education sector in England

HC 257


Child Maintenance

HC 255


Restoration and Renewal of Parliament

HC 49


The rollout of the COVID-19 vaccine programme in England

HC 258


Management of PPE contracts

HC 260


Secure training centres and secure schools

HC 30


Investigation into the British Steel Pension Scheme

HC 251


The Police Uplift Programme

HC 261


Managing cross-border travel during the COVID-19 pandemic

HC 29


Government’s contracts with Randox Laboratories Ltd

HC 28


Government actions to combat waste crime

HC 33


Regulating after EU Exit

HC 32


Whole of Government Accounts 2019–20

HC 31


Transforming electronic monitoring services

HC 34


Tackling local air quality breaches

HC 37


Measuring and reporting public sector greenhouse gas emissions

HC 39


Redevelopment of Defra’s animal health infrastructure

HC 42


Regulation of energy suppliers

HC 41


The Department for Work and Pensions’ Accounts 2021–22 – Fraud and error in the benefits system

HC 44


Evaluating innovation projects in children’s social care

HC 38


Improving the Accounting Officer Assessment process

HC 43


The Affordable Homes Programme since 2015

HC 684


Developing workforce skills for a strong economy

HC 685


Managing central government property

HC 48


Grassroots participation in sport and physical activity

HC 46


HMRC performance in 2021–22

HC 686


The Creation of the UK Infrastructure Bank

HC 45


Introducing Integrated Care Systems

HC 47


The Defence digital strategy

HC 727


Support for vulnerable adolescents

HC 730


Managing NHS backlogs and waiting times in England

HC 729


Excess Votes 2021–22

HC 1132


COVID employment support schemes

HC 810


Driving licence backlogs at the DVLA

HC 735


The Restart Scheme for long-term unemployed people

HC 733


Progress combatting fraud

HC 40


The Digital Services Tax

HC 732


Department for Business, Energy & Industrial Strategy Annual Report and Accounts 2021–22

HC 1254


BBC Digital

HC 736


Investigation into the UK Passport Office

HC 738


MoD Equipment Plan 2022–2032

HC 731


Managing tax compliance following the pandemic

HC 739


Government Shared Services

HC 734


Tackling Defra’s ageing digital services

HC 737


Restoration & Renewal of the Palace of Westminster – 2023 Recall

HC 1021


The performance of UK Security Vetting

HC 994


Alcohol treatment services

HC 1001


Education recovery in schools in England

HC 998


Supporting investment into the UK

HC 996


AEA Technology Pension Case

HC 1005


Energy bills support

HC 1074


Decarbonising the power sector

HC 1003


Timeliness of local auditor reporting

HC 995


Progress on the courts and tribunals reform programme

HC 1002


Department of Health and Social Care 2021–22 Annual Report and Accounts

HC 997


HS2 Euston

HC 1004


The Emergency Services Network

HC 1006


Progress in improving NHS mental health services

HC 1000


PPE Medpro: awarding of contracts during the pandemic

HC 1590


Child Trust Funds

HC 1231


Local authority administered COVID support schemes in England

HC 1234


Tackling fraud and corruption against government

HC 1230


Digital transformation in government: addressing the barriers to efficiency

HC 1229


Resetting government programmes

HC 1231


Update on the rollout of smart meters

HC 1332


Access to urgent and emergency care

HC 1336


Bulb Energy

HC 1232


Active travel in England

HC 1335


The Asylum Transformation Programme

HC 1334


Supported housing

HC 1330


Resettlement support for prison leavers

HC 1329


Support for innovation to deliver net zero

HC 1331


Progress with Making Tax Digital

HC 1333

1st Special Report

Sixth Annual Report of the Chair of the Committee of Public Accounts

HC 50

2nd Special Report

Seventh Annual Report of the Chair of the Committee of Public Accounts

HC 1055

Session 2021–22





Low emission cars

HC 186


BBC strategic financial management

HC 187


COVID-19: Support for children’s education

HC 240


COVID-19: Local government finance

HC 239


COVID-19: Government Support for Charities

HC 250


Public Sector Pensions

HC 289


Adult Social Care Markets

HC 252


COVID 19: Culture Recovery Fund

HC 340


Fraud and Error

HC 253


Overview of the English rail system

HC 170


Local auditor reporting on local government in England

HC 171


COVID 19: Cost Tracker Update

HC 173


Initial lessons from the government’s response to the COVID-19 pandemic

HC 175


Windrush Compensation Scheme

HC 174


DWP Employment support

HC 177


Principles of effective regulation

HC 176


High Speed 2: Progress at Summer 2021

HC 329


Government’s delivery through arm’s-length bodies

HC 181


Protecting consumers from unsafe products

HC 180


Optimising the defence estate

HC 179


School Funding

HC 183


Improving the performance of major defence equipment contracts

HC 185


Test and Trace update

HC 182


Crossrail: A progress update

HC 184


The Department for Work and Pensions’ Accounts 2020–21 – Fraud and error in the benefits system

HC 633


Lessons from Greensill Capital: accreditation to business support schemes

HC 169


Green Homes Grant Voucher Scheme

HC 635


Efficiency in government

HC 636


The National Law Enforcement Data Programme

HC 638


Challenges in implementing digital change

HC 637


Environmental Land Management Scheme

HC 639


Delivering gigabitcapable broadband

HC 743


Underpayments of the State Pension

HC 654


Local Government Finance System: Overview and Challenges

HC 646


The pharmacy early payment and salary advance schemes in the NHS

HC 745


EU Exit: UK Border post transition

HC 746


HMRC Performance in 2020–21

HC 641


COVID-19 cost tracker update

HC 640


DWP Employment Support: Kickstart Scheme

HC 655


Excess votes 2020–21: Serious Fraud Office

HC 1099


Achieving Net Zero: Follow up

HC 642


Financial sustainability of schools in England

HC 650


Reducing the backlog in criminal courts

HC 643


NHS backlogs and waiting times in England

HC 747


Progress with trade negotiations

HC 993


Government preparedness for the COVID-19 pandemic: lessons for government on risk

HC 952


Academies Sector Annual Report and Accounts 2019/20

HC 994


HMRC’s management of tax debt

HC 953


Regulation of private renting

HC 996


Bounce Back Loans Scheme: Follow-up

HC 951


Improving outcomes for women in the criminal justice system

HC 997


Ministry of Defence Equipment Plan 2021–31

HC 1164

1st Special Report

Fifth Annual Report of the Chair of the Committee of Public Accounts

HC 222

Session 2019–21





Support for children with special educational needs and disabilities

HC 85


Defence Nuclear Infrastructure

HC 86


High Speed 2: Spring 2020 Update

HC 84


EU Exit: Get ready for Brexit Campaign

HC 131


University technical colleges

HC 87


Excess votes 2018–19

HC 243


Gambling regulation: problem gambling and protecting vulnerable people

HC 134


NHS capital expenditure and financial management

HC 344


Water supply and demand management

HC 378


Defence capability and the Equipment Plan

HC 247


Local authority investment in commercial property

HC 312


Management of tax reliefs

HC 379


Whole of Government Response to COVID-19

HC 404


Readying the NHS and social care for the COVID-19 peak

HC 405


Improving the prison estate

HC 244


Progress in remediating dangerous cladding

HC 406


Immigration enforcement

HC 407


NHS nursing workforce

HC 408


Restoration and renewal of the Palace of Westminster

HC 549


Tackling the tax gap

HC 650


Government support for UK exporters

HC 679


Digital transformation in the NHS

HC 680


Delivering carrier strike

HC 684


Selecting towns for the Towns Fund

HC 651


Asylum accommodation and support transformation programme

HC 683


Department of Work and Pensions Accounts 2019–20

HC 681


Covid-19: Supply of ventilators

HC 685


The Nuclear Decommissioning Authority’s management of the Magnox contract

HC 653


Whitehall preparations for EU Exit

HC 682


The production and distribution of cash

HC 654


Starter Homes

HC 88


Specialist Skills in the civil service

HC 686


Covid-19: Bounce Back Loan Scheme

HC 687


Covid-19: Support for jobs

HC 920


Improving Broadband

HC 688


HMRC performance 2019–20

HC 690


Whole of Government Accounts 2018–19

HC 655


Managing colleges’ financial sustainability

HC 692


Lessons from major projects and programmes

HC 694


Achieving government’s long-term environmental goals

HC 927


COVID 19: the free school meals voucher scheme

HC 689


COVID-19: Government procurement and supply of Personal Protective Equipment

HC 928


COVID-19: Planning for a vaccine Part 1

HC 930


Excess Votes 2019–20

HC 1205


Managing flood risk

HC 931


Achieving Net Zero

HC 935


COVID-19: Test, track and trace (part 1)

HC 932


Digital Services at the Border

HC 936


COVID-19: housing people sleeping rough

HC 934


Defence Equipment Plan 2020–2030

HC 693


Managing the expiry of PFI contracts

HC 1114


Key challenges facing the Ministry of Justice

HC 1190


Covid 19: supporting the vulnerable during lockdown

HC 938


Improving single living accommodation for service personnel

HC 940


Environmental tax measures

HC 937


Industrial Strategy Challenge Fund

HC 941


1 C&AG’s Report, Reforming adult social care in England, Session 2023–24, HC 184, 10 November 2023

2 C&AG’s Report, paras 1.3, 1.4

3 C&AG’s Report, para 1.4

4 C&AG’s Report, paras 1.14, 1.16

5 C&AG’s Report paras 2.16, 2.17

6 Committee of Public Accounts, Introducing Integrated Care Systems, Thirty-Fifth Report of Session 2022–23, HC 47, 23 January 2023

7 Committee of Public Accounts, Introducing Integrated Care Systems, Thirty-Fifth Report of Session 2022–23, HC 47, 23 January 2023

8 Department of Health and Social Care, Government response to the Committee of Public Accounts on the Thirty fifth report from Session 2022–23, 12 April 2023

9 Q 19

10 Q 20

11 RSE0004

12 RSE0031

13 Qq 22, 23

14 Qq 25–27

15 Qq 29–31

16 Letter from DHSC to Committee, 1 February 2024

17 Q 10; C&AG’s Report, para 2.7

18 C&AG’s Report, para 2.18

19 C&AG’s Report, para 2.7

20 Q 12

21 RSE0003

22 RSE0023

23 RSE0027

24 Q 55; C&AG’s Report, para 1.10

25 Q 12

26 RSE0005

27 RSE0004

28 RSE0014,

29 Qq 10, 56–60

30 Qq 58–60

31 Committee of Public Accounts: Alcohol treatment services, Fifty-Fourth Report of Session 2022–23, HC 1001, 24 May 2023; and Reducing the harm from illegal drugs, Eleventh Report of Session 2023–24, HC 72, 9 February 2024

32 Committee of Public Accounts, Adult Social Care Markets, Seventh Report of Session 2021–22, HC 252, 16 June 2021

33 C&AG’s Report, para 7

34 RSE0013

35 Qq 3–5

36 Qq 107–115; Department for Levelling Up, Housing and Communities, Final local government finance settlement: England, 2024 to 2025, 5 February 2024

37 Qq 86–91

38 Committee of Public Accounts, The adult social care workforce in England, Thirty-Eighth Report of Session 2017–19, HC 690, 9 May 2018; Comptroller and Auditor General, The adult social care workforce in England, Session 2017–19, HC 714, National Audit Office, 8 February 2018

39 Q 34; C&AG’s Report, para 1.8, Figure 2

40 Qq 16, 33, 34; C&AG’s Report, para 1.8

41 Q 17

42 Department Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, December 2021, white paper, CP 560

43 Q 44

44 Q 46

45 Qq 39–43; RSE0021

46 Q 47; Committee of Public Accounts, Adult Social Care Markets, Seventh Report of Session 2021–22, HC 252, 16 June 2021

47 Q 47

48 Department Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, December 2021, white paper, CP 560

49 RSE0023

50 RSE0024

51 Q 49

52 RSE0003

53 RSE0007

54 Qq 49, 50

55 Q 64; C&AG’s Report, Figure 7

56 Qq 64–70

57 Q 65; C&AG’s Report, paras 15, 3.11, Figure 7

58 Q 64

59 Qq 75–78

60 Letter from DHSC to the Committee of Public Accounts, 1 February 2024

61 Qq 66–68

62 Letter from DHSC to the Committee of Public Accounts, 1 February 2024

63 C&AG’s Report, paras 3.2, 3.8

64 C&AG’s Report, para 17, Qq 63

65 Qq 11, 63

66 Q 63

67 Q 79

68 C&AG’s Report, para 3.14

69 Q 80

70 Q 82

71 Qq 82, 95–97