A critical juncture for public services: lessons from COVID-19 Contents

Chapter 5: The fragility of adult social care

87.Debra Baxter, from Wigan, has cerebral palsy. She participated in a focus group of people with complex health and social care needs that was facilitated by HealthWatch, an organisation which represents users of health and social care services.92

88.She told us: “If it wasn’t for the support of my daughter during lockdown, I wouldn’t have been able to cope.” Debra needs help with daily tasks such as getting washed and dressed. Even before the first lockdown she was struggling to get the support that she needed. The poor wages and conditions in social care result in around a third of employees leaving the sector within 12 months of starting work. We heard that Debra’s carers would often leave in quick succession, with little or no notice.

89.Once the pandemic began, the lack of adequate Personal Protective Equipment [PPE] and testing for the domiciliary care system meant that Debra felt forced to rely on her daughter:

“I eventually found a care agency that was prepared to come in, but because they were visiting other residents who could have COVID-19, I was very worried for my own health, even for my life. If it was not for my daughter being furloughed from her full-time job, I would have been left struggling.”93

90.While the crisis in acute health care caused by the COVID-19 pandemic was dealt with relatively successfully, it was followed by a devastating crisis in adult social care. Older people and the working-aged disabled with care needs were left particularly vulnerable. The large number of deaths among these groups was frequently presented by our witnesses as the most significant public service failing during the pandemic.

91.We heard that several pre-existing fundamental weaknesses contributed to the high mortality rate. These included a lack of integration between health and social care, and successive governments prioritising funding for NHS acute services and neglecting to fund social care adequately. Ministers have direct responsibility for the NHS, while responsibility for the commissioning and funding of social care services rests with local authorities. This chapter explores how the fundamental weaknesses of social care provision increased the vulnerability of people like Debra during the pandemic.

Care sector fragility before COVID-19

92.The Association of Directors of Adult Social Services set out how, prior to the pandemic, adult social care was already facing “significant and ongoing challenges”. These included “short-term and time-limited funding settlements”; growing demographic pressures which led to increasing unmet need; a lack of funding for prevention and early intervention; and difficulties in recruiting and retaining care workers due to a lack of career progression and structure.94

93.Parliamentary inquiries have focused on the need to fund adult social care more effectively, and to integrate the NHS and social care systems. The House of Lords Economic Affairs Committee called for a long-term funding solution in a 2019 report; the House of Commons Health and Social Care Committee came to a similar conclusion in October 2020.95 Kate Terroni, the Chief Inspector of Adult Social Care at the Care Quality Commission (CQC), told us: “Poor integration of services remains one of the drivers of unmet need and concerns about access to services, which impacts on person-centred care.”96 A promised white paper on social care has now been delayed until 2021 at the earliest.97

The effects of COVID-19

94.The Nuffield Trust, a health think tank, suggested that “the COVID crisis” had highlighted “the stark inequities between the health and social care services”.98 Age UK wrote that the pandemic had “laid bare the deep and systemic inadequacies of the current social care system” and revealed the “true extent of the impact that underfunding, structural issues and market instability have had on the system’s ability to respond and protect older people at a time of crisis”.99

95.The result was “a tragic loss of life”. The Office for National Statistics (ONS) reported that between 2 March and 12 June 2020 there were around 20,000 deaths of care home residents attributable to COVID-19 in England and Wales; and between 10 April and 19 June, there were 819 deaths from COVID-19 of people receiving domiciliary care in England (care provided at home by a registered care agency).100 Age UK suggested that the true figure of domiciliary care deaths could be higher because recipients were less likely to have had their deaths attributed to COVID-19 than care home residents.101 Overall, between 10 April and 19 June, the number of deaths of domiciliary care recipients was 6,523. This was 3,628 deaths more than the average for the same period (2,895 deaths) in the previous three years.102

96.We heard from ADASS that the historical tendency to prioritise acute health care had influenced the response to COVID-19. It suggested that “the initial pandemic response made protection of the NHS a priority”, which had a “detrimental impact” on social care. Patients were “discharged from hospital [into care homes] as quickly as possible, often without testing” and a “lack of PPE” for care workers contributed to the high death rate.103 The Nuffield Trust highlighted the “rapid clearing of hospital beds in the early stages of the crisis”, which revealed “too little consideration of the fragility and lack of preparedness of the care settings into which many people were being discharged”.104

97.The Nuffield Trust underlined funding disparities during the pandemic response. While the NHS “received generous emergency funding from the Treasury” at the early stage of the outbreak, which enabled “dramatic expansions in acute capacity”, care providers “raised concerns that extra funding was not reaching them”.105

98.Our evidence suggested that the failures in adult care resulted from insufficient planning. The Nuffield Trust noted that although the Government’s 2016 pandemic planning exercise, Exercise Cygnus,106 had shown that care homes and domiciliary care “would be in need of significant support in a pandemic scenario”, no advance arrangements were put in place to meet those needs:

“Even when the need became clear at an early stage in the coronavirus pandemic, the national response appears to have been confused and inadequate. The action plan for social care was published on 15 April. This was almost a month after the action plan for health services which was issued on 17 March and had important implications for the social care sector.”107

99.The Nuffield Trust’s description of Exercise Cygnus was confirmed in a Government paper on the UK’s pandemic preparedness, published on 20 October 2020.108

100.The Nuffield Trust concluded that integration between health and social care hinged on reform in three key areas: “COVID-19 demonstrated that effective integration requires parity of resource, equal visibility and priority in policy-making, and commitment to better data collection and sharing.”109 In Chapter 7 we describe how local-level Integrated Care Systems achieved effective integration during the pandemic. The devolved administrations have made several attempts to integrate health and social care, with varying degrees of success. We outline the pandemic response of their health and social care sectors in Chapter 12.

101.The COVID-19 pandemic has accentuated the systemic frailties in the care sector, with the tragic consequence of a large number of deaths in care homes and domiciliary care settings. Reform is now more urgent than ever.

102.In recent years much has been written about the lack of integration between health and social care and the need to provide adequate funding for social care. The problem of fragmentation of services is understood, but no priority has been given to creating coordinated services on the ground.

103.Closer integration and equality between health and social care will require Government action in three key areas. The fragility of adult social care should be addressed by providing the sector with adequate funding; the Government should give social care equal visibility and priority to health care; and the two sectors should integrate data collection and share data more effectively.

104.The Government should commit at the earliest opportunity to an interim sustainable funding settlement for adult social care. The Government has delayed the publication of its white paper on the long-term funding, integration and reform of the sector. This should be published as a matter of urgency.

105.We are concerned that the Government’s own pandemic planning had identified that social care would need significant support during the outbreak of a disease like COVID-19, yet social care was the poor relation to the NHS when it came to funding. In reviewing its pandemic planning processes the Government should explain how it will ensure that the social care sector receives adequate funding, resources and support while COVID-19 continues, and in any future pandemic.

92 Written evidence from HealthWatch focus group (PSR0117)

93 Q 142

94 Written evidence from Association of Directors of Public Health (ADASS) (PSR0089); see also Care Quality Commission (CQC), ‘State of Care’ (16 October 2020): https://www.cqc.org.uk/publications/major-report/state-care [accessed 16 October 2020].

95 Economic Affairs Committee, Social care funding: time to end a national scandal (7th Report, Session 2017–19, HL Paper 392) and Health and Social Care Committee, Social Care: funding and workforce (Third Report, Session 2019–21, HC Paper 206). At the time of the publication of this report, the Government had not responded to the Economic Affairs Committee. The Government is required to respond to Parliamentary Select Committee reports within two months of their publication.

96 Written evidence from Care Quality Commission (CQC) (PSR0086)

97 Heather Jameson, ‘ADASS issues stark warning as White Paper faces further delays’, Municipal Journal (17 September 2020): https://www.themj.co.uk/ADASS-issues-stark-warning-as-White-Paper-faces-further-delays/218653 [accessed 23 October 2020] and HL Deb. 15 September 2020, col 1121

98 Written evidence from Nuffield Trust (PSR0041). See also Q44 (Professor Dame Donna Kinnair).

99 Written evidence from Age UK (PSR0028)

100 Office for National Statistics, ‘Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 12 June 2020 and registered up to 20 June 2020 (provisional) (3 July 2020), section 8’: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsinvolvingcovid19inthecaresectorenglandandwales/deathsoccurringupto12june2020andregisteredupto20june2020provisional#deaths-of-recipients-of-domiciliary-care-in-england [accessed 7 November 2020]

101 Written evidence from Age UK (PSR0028)

102 Office for National Statistics, ‘Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 12 June 2020 and registered up to 20 June 2020 (provisional) (3 July 2020), section 8’: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsinvolvingcovid19inthecaresectorenglandandwales/deathsoccurringupto12june2020andregisteredupto20june2020provisional#deaths-of-recipients-of-domiciliary-care-in-england [accessed 7 November 2020]

103 Written evidence from Association of Directors of Public Health (ADASS) (PSR0089)

104 Written evidence from the Nuffield Trust (PSR0041)

105 Ibid.

106 HL Deb. 9 June 2020, col 1636

107 Written evidence from the Nuffield Trust(PSR0041). The adult social care action plan can be accessed from the Department of Health and Social Care, ‘Coronavirus (COVID-19): adult social care action plan’ (15 April 2020): https://www.gov.uk/government/publications/coronavirus-covid-19-adult-social-care-action-plan [accessed 7 November 2020]. The ‘Next steps on NHS response to COVID-19’ is at Letter from Sir Simon Stevens, NHS Chief Executive and Amanda Pritchard, NHS Chief Operating Officer to Chief Executives of all NHS trusts and foundation trusts on next steps on NHS response to COVID-19 (17 March 2020): https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/20200317-NHS-COVID-letter-FINAL.pdf [accessed 30 October 2020]. We discuss the importance of data collection and sharing in Chapter 8.

108 Department of Health and Social Care, UK pandemic preparedness (5 November 2020): https://www.gov.uk/government/publications/uk-pandemic-preparedness/uk-pandemic-preparedness [accessed 7 November 2020]

109 Written evidence from the Nuffield Trust (PSR0041)

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