Chapter 2: Challenges
8.This chapter examines political and policy challenges within the social care system. It considers Government attempts to reform social care funding and why they have proved difficult, before moving onto those issues of underfunding and unfairness identified in the previous chapter.
Political challenges of reform
9.There have been numerous attempts by governments to address the funding of social care in the last 20 years. The Voluntary Organisations Disability Group said that since 1998 there had been “12 green papers, white papers, other consultations, and five independent reviews” that attempted to solve the issues of social care funding. Some of these attempts are summarised in Box 3.
Box 3: Government reviews and attempted reforms of social care funding since 1999
|
Source: House of Commons Library, Social care: forthcoming Green Paper (England), Briefing Paper, 8002, 13 May 2019
10.These attempts have not succeeded in addressing the challenges. Care England said they were “frustrated by the lack of progress” despite all the reviews, “all of which seem to come to similar conclusions—the system needs to be properly funded.” The Institute for Government explained how some of the proposals became contentious politically:
“Proposals included in a government discussion paper in 2010 on how to fund free social care were quickly dubbed a ‘death tax’ by the Conservative opposition and dogged the Labour Party throughout that year’s election. During the 2017 election campaign the shoe was on the other foot. The Conservatives’ social care manifesto commitment quickly became known as the ‘dementia tax’ and is widely seen as contributing to the Government losing its majority … Painful precedents such as these mean that political parties are reluctant to discuss how to raise money to fund health and social care.”14
11.The Local Government Association said “national governments past and present have tended to put political prospects ahead of difficult but necessary decision-making.”15
Cross-party consensus
12.Witnesses called for a cross-party consensus on any solution. The Institute for Government said: “a minority government muddling through or acting decisively on its own is highly unlikely to achieve a long-term sustainable funding solution.”16
13.The Secretary of State acknowledged this was one of the main reasons a solution had not yet been found: “The main political parties have not yet come together across the divide to agree this” and that it would be wise for a discussion between parties to take place “outside the immediacy of an election cycle.”17 The Nuffield Trust said that new proposals “are often put forward as part of election campaigns at a point in the electoral cycle when there is minimal incentive for cross-party cooperation.”18
Public understanding
14.Some witnesses believed a lack of public understanding of the social care system was hindering reform. Care England said there was “a hesitancy by politicians to increase funding for a system that is not well understood by the public”.19 The Health Foundation said that one of the “political challenges” was that the Government needed to raise awareness of the problems with the current system: “raising awareness of these problems is a risky thing to do … But you can’t have a conversation about solutions to the social care challenges unless the public is informed.”20
15.Iain MacBeath, Director of Adult Services at Hertfordshire County Council, said there was a need to ask “some urgent questions” about the gap between people’s needs and expectations and have a “transparent conversation with the public about what is available from the state and what is not”.21
Complexity of the present system
16.The complexity of the present system was cited by witnesses as a barrier to public understanding. A Local Government Association survey found that 48 per cent of English adults said they had “little to no understanding of what the term ‘social care’ means”, 44 per cent thought social care was provided by the NHS and 28 per cent thought social care was free at the point of access.22
17.The King’s Fund and the Health Foundation published a joint report into public attitudes to social care in 2018. The Health Foundation said that the reaction to the current funding model “was unanimously negative. People were often shocked when the details of the means test were explained to them.”23
18.Kari Gerstheimer, Director of Information and Advice at Mencap, said the system was “confusing”; even people working for the charity’s information and advice service struggled “to help people navigate that extraordinary complex system.”24 Caroline Abrahams, Charity Director at Age UK, believed that reforms such as that proposed by the Dilnot Commission “would have been almost impossible to communicate to the public. I am not sure that you would ever succeed in raising public awareness.”
19.Cross-party cooperation will be necessary if progress is to be made on reforms to social care funding. It will be easier to achieve if reforms make the system easier to understand. Evidence shows that people who have not had direct exposure to the social care system do not appreciate the extent to which people are responsible for paying for their own care, and that the system is too complex. This inhibits discussion around reform, as proved by the ‘death tax’ and ‘dementia tax’ refrains in recent election campaigns.
20.After decades of reviews and failed reforms, it is not clear how another Green Paper is going to make progress on addressing the challenges in social care funding. With each delay the level of unmet need in the system increases, the pressure on unpaid carers grows stronger, the supply of care providers diminishes and the strain on the care workforce continues. Government action, rather than further consultation, is required.
21.To avoid further delay, the Government should produce a White Paper, not a Green Paper, with clear and plausible proposals for sustainable adult social care funding.
22.Our inquiry found that there were three main challenges within the social care system: a lack of funding, unfair outcomes for individuals using the care system and workforce retention and recruitment.
Funding for adult social care
23.Witnesses were agreed that there was inadequate funding for adult social care and that increases in the proportion of working age people with care needs and an ageing population would increase this ‘funding gap’. We also heard there were substantial unmet care needs and that the system was dependent on a large number of unpaid carers.
Inadequate funding
24.Local authorities spent around £18 billion gross on adult social care costs in 2017/18.25 Over half of local authorities overspent against their adult social care budgets in 2017/18 and just under half financed that overspending from their reserves.26 While short-term injections of funding have increased funding since 2015/16, Figure 1 shows that funding was still £700 million lower in 2017/18 than in 2010/11. This does not account for increases in care demand in the intervening period, meaning funding per head is even lower.
Figure 1: Adult social care spending, 2010/11 to 2017/18 (adjusted for inflation)
Source: Adult Social Care Activity and Finance Report, NHS Digital, cited by the King’s Fund: https://www.kingsfund.org.uk/publications/social-care-360/expenditure [accessed 22 May 2019]
Rising demand for adult social care
25.At the same time as funding has been under pressure, demand for care services has been increasing and is expected to continue rising. The Nuffield Trust said:
“by 2040, around one quarter of the UK population is projected to be over 65 years old and 8 per cent will be 80 years old or more. Based on current spending and population projections, a funding gap of £18 billion will open up by 2030/2031. The implications for the funding challenge are stark: by 2040, for every 2 working-age adults in the UK, there will be almost 1 person over 65 years of age.27
Researchers from the University of East Anglia, London School of Economics and Pensions Policy Institute estimated that the costs of care for older people would double between 2020 and 2035.28
26.The proportion of the working-age population with disabilities is also expected to increase. The Voluntary Organisations Disability Group (VODG) told the Committee that by 2025 there would be 150,000 more working age adults with moderate or severe physical disabilities, and 16,000 more with learning disabilities.29 Hft, a charity which supports people with learning disabilities, said people with learning disabilities “are living longer and displaying increasingly complex support needs.”30
A ‘tipping point’?
27.The combination of funding pressures and increased demand led the Care Quality Commission to warn in 2016 that adult social care was approaching a “tipping point”:
“The fragility of the adult social care market is now beginning to impact both on the people who rely on these services and on the performance of NHS care. The combination of a growing and ageing population, more people with long-term conditions, and a challenging economic climate means greater demand on services and more problems for people in accessing care.”31
28.Care England said similarly that:
“time was running out for social care … Relentless pressures on funding, increases in the level and complexity of need and widespread challenges in the retention and recruitment of the workforce required are compounding at an exponential rate, putting the continuity of care of thousands of vulnerable people at great risk.”32
Unmet demand
29.Many witnesses told us that substantial numbers of people who need care are not being provided it. Age UK estimate 1.4 million older people, 14 per cent of those over 65, have unmet care needs.33 Iain MacBeath said: “councils are really only meeting the needs of people who have substantial or critical needs”.34 He said the number of people receiving social care had “massively reduced over the period of austerity.”35 Inclusion London, a disability equality organisation, described the impact on disabled people:
“Disabled people are receiving an extremely basic ‘clean and feed’ model of care. The most basic choices such as when to get up, go to bed or use the toilet, when and what to eat, and the choice to leave the house are no longer in the hands of disabled people but subject to local authority budget allocations which are becoming ever more restricted.”36
30.A 2018 survey by the Care and Support Alliance found that as a result of a lack of support:
- “Over a quarter of respondents reported being unable to maintain the basics like washing, dressing and/or visiting the toilet.
- 1 in 5 respondents felt unsafe moving around their home, and over a third didn’t leave their homes.
- 1 in 5 respondents said they went without meals.
- 1 in 4 respondents said they needed hospital treatment and 1 in 8 told us they’ve been delayed leaving hospital.”37
Reduced eligibility for public support
31.The number of people who are eligible for publicly-funded care has reduced in recent years as the threshold used in the means test to determine whether a person becomes eligible—if they have assets worth £23,250 or below—has not increased with inflation, and therefore decreased by 12 per cent in real terms.38 If the means test had increased annually with inflation since it was last increased in 2010/11, it would now be £2,811 higher.39 The Health Foundation said this had allowed the Government to “go unnoticed in making fiscal savings.” They said over 400,000 fewer older people accessed publicly-funded social care in England in 2013/14 than in 2009/10, a 26 per cent fall despite the rise in the population of older people over the same period.40
32.Shaping Our Lives, a national network of service users and disabled people, argued local authorities were also making it harder for individuals to pass the needs assessment for public funding:
“If a council deems a need to be ‘eligible’ the need must be met as a matter of legal duty without delay. However, councils have carte blanche to define ‘need’ in whatever way they want. There are national eligibility criteria, but these are so loose as to be virtually meaningless … In this way councils can meet their fiduciary duty to spend within budget. In effect, it is significance of impact on budget, not wellbeing, that determines whether needs will be deemed ‘eligible’.”41
Required additional funding
33.To maintain existing levels of provision, the King’s Fund and the Health Foundation estimated adult social care will require an increase in annual funding of £1.5 billion by 2020/21 (to maintain 2015/16 levels of provision).42 ADASS estimate local authorities will require £2.4 billion of additional funding for 2019/20.43 Such additions would stop the funding gap widening but would not relieve substantially unmet care needs or pressure on carers.
34.The King’s Fund and Health Foundation estimate that to restore provision to 2009/10 standards of care, adult social care would require £8 billion in extra funding.44 Age UK estimated that there were still more than 800,000 people living with unmet care needs in 2010.45
Unpaid carers
35.These funding estimates assume that the level of unpaid care that is provided presently by carers is sustainable. Increasing pressure is being placed on friends or family members to provide informal care. According to the 2011 census, there were 5.4 million unpaid carers in England. Nearly a quarter of them provided 50 or more hours of care a week, as shown in Table 2. 46
Table 2: Numbers of unpaid carers in England by amount of care provided, 2011
Number of unpaid care hours provided a week |
Number of people |
|
1 to 19 |
3,452,636 |
|
20 to 49 |
721,143 |
|
50 or more |
1,256,237 |
|
Total |
5,430,016 |
Source: Office for National Statistics, 2011 Census
36.Some witnesses told us that with reduced local authority funding, informal carers were doing more, and with less support. Carers UK said:
“The rationing of social care services due to funding cuts is resulting in extreme and unsustainable pressure being placed on carers, who are providing more care, for more hours than ever before. Since 2001, the growth in the number of carers has outstripped population growth by 16.5 per cent and the number of people providing 20–49 hours of care a week has increased by 43 per cent.”47
Eighty-one per cent of people answering the Care and Support Alliance’s survey mentioned above said family and friends are being expected to provide more care as local authority funding has been restricted.48 The Alzheimer’s Society told us that unpaid carers “bear the brunt of the social care funding crisis”.49
37.Carers UK said unpaid carers were receiving less support. As the care packages the person supported receives decrease, carers “are finding it harder to access the breaks they need to look after their own health and well-being”.50 They noted that spending on carers decreased by 6 per cent between 2017 and 2018, and the number of carers getting support or being assessed by local authorities decreased by five per cent.51
38.A 2018 survey by Carers UK found a large proportion of carers reported that their health had declined as a result of caring: 72 per cent mentally and 61 per cent physically.52 Thirty-seven per cent of respondents said they were “struggling to make ends meet” financially.53 Carers UK argued that, given this impact on carers, any long-term adult social care solution should not assume that current levels of unpaid care can continue:
“Our evidence from carers shows that any economic modelling which is predicated on the unpaid support of families and friends continuing to care in good health, or being able provide the same level of care in the future, would be deeply flawed.”54
39.Fifty-eight per cent of unpaid carers are women, with those aged 50–64 particularly likely to have care responsibilities. 63 per cent of female carers aged 50–64 provide care for at least 50 hours a week. The Women’s Budget Group said that as more women entered the workplace, this supply of unpaid carers was likely to fall.55
40.As fewer individuals have been able to access local authority funding, greater pressure has fallen on family and friends to provide unpaid care. This may not be sustainable. Restoring access to local authority funding for many individuals could help to relieve this pressure.
41.To restore care quality and access to 2009/10 standards, addressing the increased pressure on unpaid carers and local authorities and the unmet need that has developed since then, around £8 billion a year in additional funding will be required for adult social care. More will be required in subsequent years as the population of older and working-age people with care needs continues to grow.
Unfairness
42.Witnesses to our inquiry were in broad agreement that the present social care system in England is unfair. The Health and Social Care Secretary said: “there is a whole series of ways in which the existing system is unfair, and it is hard to see a single solution that solves all those injustices.”56 Witnesses mentioned three main types of unfairness: disparities between adult social care and the National Health Service, those who fund their own care and those who receive local authority funding, and between different local authorities.
The ‘condition lottery’ and catastrophic costs
43.Several witnesses pointed out the disparity between conditions for which people receive health care, which is free at the point of use, and those for which people receive social care, for which users usually make a substantial contribution (as detailed in Chapter 1). Dominic Carter, Policy Manager at the Alzheimer’s Society, said:
“there is a growing and angry understanding that if you develop many different conditions you will get free support through the NHS, but if, like many, you develop dementia most of the responsibility for paying for care will fall on you and your family, meaning that of the £26 billion that dementia costs every year, two-thirds is being shouldered by the individuals concerned.”57
44.Warwick Lightfoot, Head of Economics and Social Policy at Policy Exchange, described how the disparity between health and social care came about:
“When we set up the National Health Service in the 1940s, the decision was made that social care would be financed by individuals until they fell into the hands of the social security system and came under the National Assistance Act 1948. We have now got to the stage where many more people have complex and difficult social care needs, and they have to finance themselves until they are cleaned out of their financial assets, yet a whole range of other medical needs are dealt with totally free.”58
45.Dementia was cited by several witnesses as an example of this disparity.59 The costs of caring for this condition and the fact that the costs can be incurred over a long period can involve “catastrophic costs” to individuals, which can lead to them being forced to sell their home. The Alzheimer’s Society estimate typical dementia care costs to be roughly £100,000, rising to £500,000 in some cases.60 Sir Andrew Dilnot, who chaired a Government-commissioned review which reported in 2011, said:
“One way of describing the current system is that it is a very high inheritance tax, but only on people who have high social care needs. That is the unfairness. If we want the inheritance tax regime to take more money away from the person with £2.5 million than it does from the individual with £500,000, let us do it for 100 per cent of those in that circumstance, not for 10 per cent of them … the person with £2.5 million who has no social care needs [is] completely untouched by anything. It is only the very small subset of people with high social care needs who get hit.”61
46.The Health and Social Care Secretary said: “the threat that people might lose their home because of something they cannot do anything about or insure against is one of the injustices of the system.”62
Self-funders, local authority fees and market sustainability
47.Individuals who pay the full cost of their care (known as self-funders) often pay higher rates for care homes than those whose costs are funded by the local authority. Witnesses told us this was unfair both for self-funders, because they were paying higher fees, and for local authority-funded individuals, because it gave care providers an incentive to focus on self-funders to the detriment of other provision.
48.The Competition and Markets Authority estimated in their study of the care homes market that self-funders paid 41 per cent higher fees than the local authority rate in 2016.63 They found that this differential had increased substantially since 2005, when only one in five care homes charged different prices for the two groups.64 The report concluded:
“The consequence is that self-funded residents in mixed homes are meeting a much greater proportion of homes’ fixed costs than LA-funded residents. This is often referred to in the industry as a ‘cross-subsidy’.”65
49.Sarah Pickup, Deputy Chief Executive of the Local Government Association, said the cross-subsidy was “not fair” to self-funders.66 Professor Jill Manthorpe, Director of the National Institute for Health Research Health and Social Care Workforce Research Unit, described it as “taxation by other means”.67
50.Professor Martin Green OBE, Chief Executive of care provider representative Care England, argued the disparity resulted from low local authority fees, not overcharging of self-funders:
“We should not see it as a cross-subsidy; we should see it as one lot of people probably paying the real costs of care, and local authorities not doing so. I do not think that people realise how low those figures are. In Windsor and Maidenhead, for example, they pay £2.48 an hour to deliver care to people who have several health problems, many of whom are living with dementia. Those figures are totally unsustainable … How is anybody supposed to deliver a quality service on that level of funding? It is not possible.”68
51.There were also concerns that low local authority fees threatened the overall sustainability of the market. Professor Green said that some smaller providers which could not “make economies of scale” were exiting the market.69 Larger providers have also faced difficulties. Home care provider Allied Healthcare was sold in late 2018 after announcing it was selling or transferring all of its contracts,70 and in April 2019 care home operator Four Seasons Health Care, which houses 22,000 people in 322 homes, went into administration.71 The 2018 ADASS Budget Survey stated that providers had handed back contracts to more than 60 local authorities, impacting just under 3,000 people in 2018/19.72
52.Some witnesses were concerned that a “two-tier” care homes market was emerging.73 Witnesses suggested more care providers were choosing to market services predominantly at self-funders in order to remain sustainable. Douglas Cooper, Project Director of the Competition and Market Authority’s care homes market study, said:
“There are strong incentives for homes in a local market where they can rely solely on self-funders. Without the cross-subsidy element, they can offer better deals, better value and better quality for the self-funded residents. The consequence will be that local authority-funded residents will be pushed out and the quality of care, if any care is provided to them, is likely to diminish over time.”74
Iain MacBeath, Director of Adult Social Care Services at Hertfordshire County Council, said that one care home in his area focused predominantly on self-funders cost £2,500 a week, while the local authority paid care homes £560 a per resident.75
53.The Health and Social Care Secretary suggested he did not think the situation was unsustainable:
“You ask if it is sustainable. It has been going on for quite a long time. If you were designing a perfect system, of course you would not have such a disparity. At the same time, local authorities buy in bulk and can predict the amount of demand they are going to have. I look at it as a feature of the system rather than something that anybody designing this system from scratch would put in place.”76
54.Unlike the Secretary of State, we are convinced that the increasing disparity between prices paid by self-funders and those paid by local authorities is unfair to both sides and therefore unsustainable. The effect is to drive care homes to market to self-funders, and so reduce the availability of places for individuals funded by local authorities.
Regional differences
55.Witnesses agreed that the impact of the disparity between care costs for self-funders and local authorities was greater in areas with a higher proportion of local authority-funded care users. The Health and Social Care Secretary acknowledged that higher numbers of self-funders in some areas “undoubtedly has an impact regionally”.77 Warwick Lightfoot said:
“We see evidence that, because care providers cannot get enough from local authority-commissioned places, they are beginning to withdraw from areas where there is an insufficient number of self-funders. In some places, where property prices have gone up a great deal, and against an increasingly challenging expectation of service, regulation and inspection, some people who have run rather good homes say, ‘I have a substantial capital gain on this premises and, in an orderly way, I would like to move out of the market, call it a day and cash in the capital gain and convert it into flats, or whatever’.”78
56.The trade union UNISON agreed:
“Financial constraints are further entrenching inequalities of provision and a north-south divide, with a risk that care companies focus on places where there are more high-paying self-funders of care (such as the south east), creating a shortage of care home places in other parts.”79
57.Professor Martin Green OBE said the system was “walking towards a postcode lottery”.80 He continued:
“If you look at the State of Social Care report, which the Care Quality Commission delivers to Parliament, you will see that there is a reduction in the overall number of beds. Underlying that, there is also the issue that the new beds are all in particular areas. There is attrition in areas that are predominantly publicly funded and new services are being developed in areas where there is more affluence and private funding.”81
Unequal demand for care
58.Some local authorities have higher populations of older people than others, leading to higher care costs. West Sussex County Council told us the population of West Sussex over 65 was projected to rise more than 53 per cent in the next 20 years.82 South East Councils said the population of those aged over 75 was higher in the south east than anywhere else in the country, and projected to double by 2041.83 Essex County Council said that 21 per cent of their population were over 65.84 Some areas will incur higher costs because a higher proportion of their population qualifies for public funding through the means test.
59.Despite attempts at national standardisation in the Care Act 2014, witnesses told us that there were differences in local authorities’ interpretation of what constituted a social care need. Warwick Lightfoot said:
“It turns on the criteria used for the basis on which you offer care. For example, some local authorities have very tightly drawn criteria before you can access care. I think I am accurate in saying that one of the few authorities that continues to offer moderate care needs is … Kensington and Chelsea. You ration the care; the gatekeepers, who are the social workers, ration care according to their budgets.”85
Unequal ability to raise funds
60.The amount local authorities can raise for social care through the Social Care Precept, normal council tax and business rates depends on the strength of their local economies. Sarah Pickup said:
“business rates and council tax cannot be the only solution for services like adult social care and children’s services, exactly because the pattern of growth in need does not reflect the pattern of growth in business rates.”86
61.The Institute for Fiscal Studies found that between 2009/10 and 2017/18 adult social care funding per head was more likely to have decreased in more deprived areas. In the most deprived areas, funding per head decreased by 17 per cent.87
62.The Government plans to increase the amount that local authorities retain from business rates from 50 per cent to 75 per cent from 2020/21 onwards,88 in exchange for the removal of several government grants. This includes the Revenue Support Grant, which can be spent on adult social care. Local authorities who raise less in business rates revenue may see a decrease in funds available for adult social care. In a recent report, the Institute for Fiscal Studies said adult social care could account for more than half of revenue from council tax and business rates by the mid-2030s, with little left over for other services such as children’s social care or housing.89 The Care and Support Alliance said:
“There are outstanding concerns both about variations in the amount different local authorities will be able to raise from business rates and whether business rates will replace the revenue support grants as a sustainable source of income to enable them to meet their social care responsibilities.”90
63.The Care Quality Commission’s 2018 State of Care report raised concerns about regional variation in the quality of care provision. 91 The Department of Health and Social Care acknowledged regional differences in quality and committed to consider this as part of its forthcoming Green Paper.92
64.Jonathan Marron, Director General for Community and Social Care at the department, told the Committee that the Government already attempts to redistribute funds according to need:
“Some of the money in the £10 billion that the Secretary of State has talked about comes from the improved better care fund (iBCF), a grant from government to local authorities. That was set up to try to have a further redistributive effect. Areas less likely to raise money from the precept were given more from the iBCF, so the details of the arrangement were quite complicated, but we were trying to address exactly your point about some local authorities having less spending power.”93
65.Local authorities differ in respect of the cost pressures they face and their ability to raise funds. Some local authorities are therefore able to spend more per head on adult social care than others, leading to a postcode lottery in standards of provision.
66.We share the concerns of many witnesses about the Government’s plans to make local authorities more fiscally self-reliant. Demand for social care is often greatest in areas where business is least buoyant.
Workforce
67.Many witnesses praised the work ethic and integrity of staff in the care sector. Sir Andrew Dilnot said:
“It is easy to neglect how wonderful the people providing this care are and, by and large, they are fabulous people working in circumstances that many people would not find desirable.”94
68.Sharon Allen OBE, chief executive officer of Skills for Care, said:
“The other reason why we have not seen things fall over completely is the dedication and commitment of the 1.47 million people working in the sector. People in the sector develop long-term relationships with people they provide care and support to. During the “Beast from the East” last winter, for example, we saw social care workers working in residential care staying on for one or two nights extra, and we saw people going out on foot because they would not leave people without care and support.”95
Vacancies
69.The National Audit Office estimated there were 1.3 million people employed in the care workforce in 2016/17 with a 6.6 per cent vacancy rate.96 The Centre for Workforce Intelligence estimated in 2016 that an additional 660,000 jobs would be needed by 2035, if the care workforce was to grow at the same rate as the demand for care in that period.97
70.Skills for Care estimate staff turnover in the sector during 2017/18 was 31 per cent, rising to 38 per cent for care workers and 42 per cent for care workers in domiciliary providers. Turnover had increased by nearly 8 per cent since 2012/13. While much of this turnover was movement within the sector, a “large proportion” of that turnover was attributed to “people leaving the sector soon after joining”.98 The Care Quality Commission said that this turnover “has a detrimental impact on the continuity of care for people and their ability to develop meaningful relationships with the staff who support them”.99
71.Caroline Abrahams, Charity Director at Age UK, described this as a “chronic workforce shortage”:
“There is a very high turnover, and lots of people do not want to do this job, so there are places where, even if you have some money, as a self-funder you cannot buy care because there is no one there to provide it, typically in better off areas, where there are easier ways for people to earn a living.”100
72.ADASS noted that the vacancy rate in 2017/18 was highest for registered nurses, at 12 per cent:101
“Recruitment and retention issues have led to some care homes deregistering from nursing care provision, instead refocusing on residential provision. This in turn leads to a shortage of nursing care provision. There is also competition for registered nurses from the NHS, which further exacerbates the situation.”102
73.The Royal College of Nursing were concerned about the impact of high nurse vacancy rates on nurses and the quality of care:
“There are not enough registered nurses and healthcare support workers to deliver safe and effective care in adult social care settings such as nursing homes and residential care homes. Registered nurses report working unpaid overtime to fill gaps, additional stress caused by a high-pressure environment, and describe occasions when vital care is left undone. Data shows that while the number of registered nurses is declining, the number of care workers is increasing. We are concerned that inappropriate substitution of skills leads to poorer outcomes for people using these services.”103
Brexit and care workers
74.Some witnesses were concerned about the impact of the UK’s exit from the European Union on recruitment of care workers. The Nuffield Trust estimated this would increase vacancies in the workforce by 70,000.104 Caroline Abrahams said this would most affect London as around one in six care workers in London were from elsewhere in the EU.105
75.Kathryn Petrie, Senior Economist at the Social Market Foundation, noted that:
“ … the social care workforce is around 10 per cent non-UK and non-EU and about 8 per cent EU workers, so our dependence on non-EU workers is heavier than it is on EU workers. That does not necessarily mean that, with skills changes, there will not be issues, but the EU issue is not necessarily the be-all and end-all of the workforce issues. There are much more important things going on in the industry, such as attraction and retention.”106
Pay
76.Many witnesses blamed low pay for difficulties in recruitment. UNISON described the threat of competition from other sectors:
“Low pay has forced too many good workers to leave the sector because they cannot afford to stay; with care homes facing a recruitment crisis as competing employers, such as discount supermarkets, are actively recruiting and offering more attractive pay rates.”107
Iain MacBeath noted that the lowest-paid workers in the NHS were due pay rises of between 9 and 29 per cent over the next three years, which could encourage care staff to move to the health sector.108
77.In January 2019, we held a private roundtable discussion with care workers from an Oxfordshire care home. They agreed that competition from supermarkets was a problem, particularly in urban areas. They also highlighted competition within the sector for workers in care homes. Care homes which relied more on self-funders could afford to pay more than those predominantly reliant on local authority funding. In the participants’ care home, care workers were paid between £8 and £10 per hour, while self-funder homes could afford to pay between £15 and £17 per hour.109
78.The Health and Social Care Secretary told us that pay for care workers had increased in line with recent minimum wage increases:
“We have seen some very sharp rises, in percentage terms, in the pay of people working in social care. The national living wage has had a big impact on people working in care, because there is a higher proportion of people who were previously on the minimum wage in social care than in many professions. Part of the increase in funding that has gone in has been to ensure that pay has gone up.”110
Care as a profession
79.Care workers at the Committee’s private roundtable discussion emphasised that pay was not the only reason for high turnover rates in the social care workforce. One participant described two types of people who worked in the care sector. One type saw care work as a vocation and remained in the sector for decades. The other, a more recent entrant to the sector, was looking for short-term work to fill a gap in their career or pay the bills. The participant said: “It is not a vocation for them, it just fits their lifestyle. Something is missing … it is not seen as an attractive role anymore.”111
80.One participant said: “It is not all about money … care work is a profession and needs to be seen as such. Nurses are highly respected, highly regarded … we need to be on the same platform but are seen as second-class citizens.” Another participant noted that they had too often heard people describe themselves or others as “just a carer”.112
81.Kari Gerstheimer, Director of Information and Advice at Mencap, said:
“Our position is, first, that the phrase “low-skilled worker” should not be used in relation to care staff. We think that that perception needs to be challenged. There needs to be a greater emphasis on professional structures, career development and appropriate reward.”113
82.Harry Quilter-Pinner, Research Fellow at the Institute for Public Policy Research (IPPR), argued that care should treated a profession akin to nursing:
“Do we need a royal college equivalent to represent care workers, or a more significant skills qualification to get into the sector? I am thinking about the transformation in nursing over the past 10 or 20 years to a more professional and highly qualified role. We have to take a similar journey on social care. The argument to take to the public and politicians is to ask who we want to look after our elderly grandparents and family when they are older. Should that person have no qualifications and no support and be very low paid? Do we think that is fair?”114
83.In response, Warwick Lightfoot warned about imposing too many qualification requirements on the sector:
“We have to be very careful that we do not go down the same route as we have with nurses, because care is everything. I have certainly experienced care settings where there has been very good leadership in a particular home, with what we would call unskilled people, who have had very few opportunities to have education … The people managing the home have very real skill and know what they are doing. Often, they are quite badly paid compared with the people working in the hospital across the road. We talk about head teachers needing leadership, but it is the people who run the homes who often need leadership.”115
84.UNISON said the adult social care workforce was not taken seriously enough by the Government:
“the 142-page draft [Health and Care Workforce] strategy allocated just five pages to social care. The lack of importance attached to the development of the social care workforce is related to the wider failing to seek engagement from staff, amply illustrated by the fact that the expert panel set up to inform the green paper includes no care workers and no representatives of care workers.”116
85.The draft Health and Care Workforce Strategy, published for consultation by Health Education England in 2017, made few suggestions for reform. One section however discussed the potential introduction of professional regulation for care workers:
“Professional regulation supports the delivery of safe and high quality care through setting standards and ensuring continuing fitness to practise. Greater regulatory oversight of social care workers might be an option. A regulatory framework could also support the development of clearer roles linked to competencies, building on the Care Certificate.
While this is an opportunity, it would be more challenging to deliver in social care than the similar new role of nursing associates in health. There are fewer levers in social care to drive consistent changes in the workforce, not least the large number of small private or third-party employers in the sector.”117
86.The draft strategy suggested that, through the Government’s Green Paper, “experts, stakeholders and people using care and support services will have the opportunity to shape the long-term reform needed.”118 The Health and Social Care Secretary agreed that care work should be treated as a profession, and suggested it was an issue the department can “just get on with” notwithstanding the Green Paper.119
87.Increased funding for adult social care will allow for investment in the care workforce. Higher pay is required for care workers in publicly-funded care providers to allow those providers to compete with other local employers. The care workforce needs a career structure which better reflects the skills required to be a good care worker and the social importance of the sector.
22 Local Government Association, ‘Majority of people unprepared for adult social care costs’, (26 October 2018): https://www.local.gov.uk/about/news/majority-people-unprepared-adult-social-care-costs [accessed June 2019]. The Health Foundation highlighted polling on behalf of Deloitte which found that 47 per cent of people believed social care was free at the point of need. Written evidence from the Health Foundation (SOC0047)
25 NHS, Adult Social Care Activity and Finance Report, England 2017–18 (23 October 2018): https://digital.nhs.uk/data-and-information/publications/statistical/adult-social-care-activity-and-finance-report/2017–18 [accessed 30 May 2019]
26 Written evidence from the Association of Directors of Adult Social Services (ADASS) (SOC0052). A 2018 report from the Chartered Institute for Public Finance and Accountancy (CIPFA) showed that 10 to 15 per cent of local authorities showed signs of being financially unstable, primarily because they were depleting their reserves. They suggested adult social care funding was at least responsible in part for the vulnerability of some local authorities. CIPFA, Measured resilience in English authorities (December 2018) https://www.cipfa.org/policy-and-guidance/reports/measured-resilience-in-english-authorities [accessed 26 June 2019]
31 Care Quality Commission, Adult social care ‘approaching tipping point’, warns quality regulator (13 October 2016): https://www.cqc.org.uk/news/releases/adult-social-care-%E2%80%98approaching-tipping-point%E2%80%99-warns-quality-regulator [accessed 28 February 2019]
33 Age UK, ‘New analysis shows number of older people with unmet care needs soars to record high’, (9 July 2018): https://www.ageuk.org.uk/latest-press/articles/2018/july-2018/new-analysis-shows-number-of-older-people-with-unmet-care-needs-soars-to-record-high/ [ accessed 16 May 2019]
35 Ibid.
37 Written evidence from Care and Support Alliance (CSA) (SOC0028). Care and Support Alliance conducted a survey of 3,915 self-selecting older and working age individuals with self-identified care needs.
38 The Health Foundation, NHS at 70: What’s the problem with social care, and why do we need to do better? (June 2018): https://www.health.org.uk/publications/nhs-at-70-what%E2%80%99s-the-problem-with-social-care-and-why-do-we-need-to-do-better [accessed 16 May 2019]
39 The King’s Fund, Social care 360: https://www.kingsfund.org.uk/publications/social-care-360/access [accessed 30 May 2019]
43 Written evidence from the Association of Directors of Adult Social Services (ADASS) (SOC0052). This uses the King’s Fund and Health Foundation estimate of £1.5 billion, and adds £500 million of savings ADASS estimates directors would otherwise be asked to find from their budgets in 2019/20, £358 million in response to overspends and spending of local authority reserves on adult social care in 2017/18.
44 Written evidence from the Health Foundation (SOC0047). This is the additional amount required if local authorities had been able to increase their spending by 3.7 per cent every year since 2009/10. 3.7 per cent is the Health Foundation’s estimate of the average annual growth in social care cost pressures until 2030/31, caused by a growing and ageing population, more people living longer with long-term conditions and the rising costs of providing care.
45 Age UK, ‘1.2 million older people don’t get the social care they need’, (17 November 2016): https://www.ageuk.org.uk/latest-news/archive/12m-older-people-dont-get-the-social-care-they-need/ [accessed 26 June 2019]
46 Office for National Statistics, 2011 Census (27 March 2019): https://www.nomisweb.co.uk/census/2011/QS301UK/view/2092957699?cols=measures [accessed 30 May 2019]
51 Ibid.
52 Written evidence from Carers UK (SOC0046). The survey was UK-wide and 75 per cent of respondents were from England—Carers UK, State of Caring 2018 (July 2018): https://www.carersuk.org/images/Downloads/SoC2018/State-of-Caring-report-2018.pdf [accessed 27 May 2019]
54 Ibid..
59 Q 33 (John Godfrey), Q 42 (Dominic Carter), Q 66 (Iain MacBeath) and written evidence from The Nuffield Trust (SOC0031)
63 Competition and Markets Authority, Care homes market study: final report (30 November 2017): https://assets.publishing.service.gov.uk/media/5a1fdf30e5274a750b82533a/care-homes-market-study-final-report.pdf [accessed 26 June 2019]. This applies only in care homes which accommodated both local authority and self-funded residents. Care homes which focused exclusively on one of the two groups were excluded.
64 Competition and Markets Authority, Care homes market study: final report (30 November 2017): https://assets.publishing.service.gov.uk/media/5a1fdf30e5274a750b82533a/care-homes-market-study-final-report.pdf [accessed 26 June 2019].
65 Ibid. “Mixed homes” means homes which house both self-funded and local authority-funded residents.
70 Public Sector Executive, ‘Home care provider Allied Healthcare saved from bankruptcy’, (3 December 2018): http://www.publicsectorexecutive.com/Public-Sector-News/home-care-provider-allied-healthcare-saved-from-bankruptcy- [accessed 28 May 2019]
71 ‘Four Seasons: Care home operator goes into administration, raising fears for elderly residents’, The Independent (30 April 2019): https://www.independent.co.uk/news/business/news/four-seasons-care-home-operator-administration-residents-a8892731.html [accessed 11 May 2019]
81 Ibid.
87 The Institute for Fiscal Studies, Changes in councils’ adult social care and overall service spending in England, 2009–10 to 2017–18, (13 June 2018) p 5: https://www.ifs.org.uk/uploads/BN240.pdf [accessed 30 May 2019]
89 The Institute for Fiscal Studies, English council funding: what’s happened and what’s next? (29 May 2019): https://www.ifs.org.uk/uploads/publications/bns/BN250.pdf [accessed 6 June 2019]
91 Care Quality Commission, State of Care 2017/18 (October 2018): https://www.cqc.org.uk/publications/major-report/state-care [accessed 26 June 2019]
96 National Audit Office, The adult social care workforce in England, HC714 Session 2017–19 (8 February 2018): https://www.nao.org.uk/wp-content/uploads/2018/02/The-adult-social-care-workforce-in-England.pdf [accessed 30 May 2019]. Skills for Care estimated the vacancy rate was 8 per cent in 2017/18, Skills for Care, The state of the adult social care sector and workforce in England (September 2018): https://www.skillsforcare.org.uk/NMDS-SC-intelligence/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-2018.pdf [accessed 1 June 2019]
97 Centre for Workforce Intelligence, Forecasting the adult social care workforce to 2035 (July 2016): https://www.basw.co.uk/system/files/resources/basw_22641-9_0.pdf [ accessed 26 June 2019]
98 Skills for Care, The state of the adult social care sector and workforce in England (September 2018): https://www.skillsforcare.org.uk/NMDS-SC-intelligence/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-2018.pdf [accessed 1 June 2019]
101 Skills for Care, The state of the adult social care sector and workforce in England (September 2018): https://www.skillsforcare.org.uk/NMDS-SC-intelligence/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-2018.pdf [accessed 1 June 2019]
109 Appendix 4: Private meeting with care workers, 8 January 2019
111 Appendix 4: Private meeting with care workers, 8 January 2019
112 Ibid.
117 NHS, Facing the Facts, Shaping the Future A draft health and care workforce strategy for England to 2027 (December 2017): https://www.hee.nhs.uk/sites/default/files/documents/Facing%20the%20Facts%2C%20Shaping%20the%20Future%20%E2%80%93%20a%20draft%20health%20and%20care%20workforce%20strategy%20for%20England%20to%202027.pdf [accessed 7 June 2019]
118 Ibid.