156.Our inquiry focused on the invisibility of adult social care particularly as it relates to unpaid carers and those they provide care for. Having listened to our witnesses, we have come to the conclusion that without radical and long-term changes in the adult social care service as a whole, changes to the lives of unpaid carers can only be marginal, and the short-term and urgent changes that are needed to alleviate immediate pressures on them will be partial and unsustainable.
157.This chapter sets out the broader changes that we think are needed. We must rethink how we, as a society, appreciate the role of adult social care and of those who provide care today, and are expected to provide it tomorrow. We acknowledge the uniquely challenging funding landscape for adult social care, which has to be addressed; and we make clear that the proper resourcing of adult social care should be a national imperative, particularly to retain and enhance the status and skills of the paid care workforce.
158.In terms of immediate possibilities, however, we believe that while adult social care must be designed and delivered locally, action is long overdue to raise the national profile, infrastructure and accountability for the service. This should focus on advocacy as well as bringing challenge and status to adult social care, which will give greater voice as well as visibility to the sector.
159.We do not believe that new legislation is necessary. Existing laws must be enforced and must achieve their intent. Many solutions can be found in the Care Act 2014, which has not been appropriately implemented. The legislation should urgently be implemented, along with its guidance.
160.Finally, we look at the potential of more recent legislation, Integrated Care Systems (ICSs) and what must be done to ensure that adult social care optimises the new opportunities to raise its profile and move towards greater reengagement of those who draw on and provide care and support.
161.Without fundamentally changing our appreciation of the role of adult social care as a critical service for people and communities, and as a key investment in our society and economy, any attempt to reform the sector will falter.
162.The first challenge in achieving such a significant cultural shift is to reassert the full purpose of adult social care. We put this question to witnesses and respondents, who frequently pointed to the vision of social care that was developed by the social movement Social Care Future to make possible the rightful ambition of people who “all want to live in the place we call home, with the people and things we love, in communities where we look out for one another, doing what matters to us.” We endorse this definition, which celebrates the potential role of adult social care and reflects the ambitions, the values and the contribution of people who use adult social care services. We believe that it should steer the basis of any reform.
163.To achieve this, the national discourse will have to change. As one witness put it: “We have to stop thinking about going to social care as a disaster. Social care is an enabler.”
164.To create an enabling service means developing all the means available for people to have greater choice and control over their lives. In turn, that means deciding for themselves the kind of relationship they want to have with the people around them, whether that is family and friends, or a personal assistant to support them. While such choices do exist in principle, they are often not exercised in practice. In summary, we are looking for greater resources to enable a focus on the diverse needs of working age disabled people and older people. This will also be a first step towards developing the full range of support and opportunities for the unpaid carers now facing increasing pressure as the paid workforce declines.
165.Several changes are necessary if this is to happen. The Government must step up to the challenge of funding adult social care to attract more people into the sector and to promote their skills. Second, there is a need for more robust infrastructure, which will provide greater advocacy and agency for adult social care. The implementation—or lack of—of the Care Act 2014 must also be addressed.
166.We endorse Social Care Future’s definition of the purpose of social care: to make possible the rightful ambition of people who “all want to live in the place we call home, with the people and things we love, in communities where we look out for one another, doing what matters to us.”
167.Adult social care and the budgets of local authorities for its delivery have been chronically under-funded for many years—both a cause and a consequence of the lack of attention paid to the sector. For example, while the total budget for publicly funded adult social care in 2022/23 is £17.1 billion, the commissioning budget for the NHS for the same year is £153 billion. This is despite the fact that the adult social care workforce is larger than that of the NHS.
168.Mr Hunt told us: “The biggest gap at the moment is in local authority funding.” The LGA in turn confirmed that the origins of the current challenges in the system can largely be traced to the pressures created by years of underfunding, together with significant increases in costs. We have already discussed in previous chapters the impact that this is having on the erosion of basic services, and in turn on fundamental human relationships.
169.It is difficult to estimate the scale of the funding gap, because there is no national government budget for adult social care in England. Services are instead financed through local government revenue. According to the National Audit Office, government funding for local authorities has fallen by 55% in 2019/20 compared to 2010/11, which resulted in a 29% real-terms reduction in local government spending power. Given that spending on adult social care constitutes a significant proportion of local authority spending, this has had important implications for the delivery of services. Estimates show that spending per person on adult social care services has fallen in real terms by around 12% between 2010/11 and 2018/19 in England.
170.At the same time, the cost of adult social care is increasing as demand for services grows, aggravated by inflation and pay pressures, which will contribute to increasing the cost of care services for local authorities in the next few years. London Councils provided us with a picture of the challenges faced by local authorities in the capital, where the boroughs’ core spending power has fallen by almost a quarter in the decade since 2010, while the population grew by approximately 12% in the same period.
171.The consequences of the funding gap in adult social care mean that there are increasing levels of unmet need. One expert by experience described to us the “excessive” amount of money he has had to contribute to his care costs, and how this pushes many disabled people into poverty. “It is causing a lot of mental anguish and mental health problems. Even if it was not, it would still be morally wrong,” he told us. The Association of Directors of Adult Social Care told us that as of March 2022, toward the end of the most difficult winter most Directors of Adult Social Services had experienced, a third of councils (33%) were asking carers to provide more support to replace a reduction in commissioned support, for example by taking paid or unpaid time off work.
172.Faced with limited resources, local authorities have no choice but to reduce access to services, or to ration what is available to basic eligibility and very basic needs. We heard of councils where cuts to budgets are causing immense challenges to the delivery of adult social care to those who most needed it. Up to 97% of directors of adult social services across England recently reported feeling “pessimistic” or “very pessimistic” about the financial state of the wider health and social care economy in their local areas over the next 12 months. In that context, adopting an approach to social care that goes beyond statutory duties can be extremely challenging. Additionally, cuts in other areas of local authority spend often mean that the wider web of support that people draw on is reduced, too, which increases the pressure on social care.
173.The extent of the crisis has been in part recognised by the Health and Social Care Levy Act 2021, which is now repealed but was originally intended to introduce an additional £12 billion per year for health and social care on average over the next three years, amounting to an additional £36 billion by 2024/25. Of this, £5.4 billion would have been dedicated to the adult social care system over three years. The majority (£3.6 billion) would have been spent on capping care costs to an £86,000 limit and extending means testing, and to help local authorities pay a fair cost for care, from October 2023. Another £1.7 billion was set aside for transforming adult social care services across England. The breakdown of this £1.7 billion investment was outlined in the Government White Paper in December 2021.
The £1.7 billion investment was broken down as follows:
While figures do not add up to £1.7 billion, we were informed by civil servants that this was deliberately designed to allow for some flexibility.
174.Most stakeholders agree that these funding reforms would have been insufficient, both to ensure the sustainability of the adult social care sector and to successfully improve the quality of services. The Health Foundation, for example, told us that “significant additional investment and more fundamental reforms” are needed to provide care to everyone who needs it. Similarly, we were told that the additional funding would be insufficient to carry out the transformative reforms that the Government laid out in the White Paper. The LGA wrote that although the Government’s ambitions to transform the outcomes of care should be supported, they were “increasingly concerned that the amount of funding Government has earmarked for them is insufficient.” As one witness put it to us: “There is a mismatch coming down the line between the vision of what people should be able to do and the funding that sits alongside it.”
175.Instead of increasing the funding settlement for adult social care, however, the Government has repealed the Health and Social Care Levy Act, as well as some of its funding and reform pledges. The Chancellor, Mr Hunt, committed in the latest Autumn Statement to increasing the funding for healthcare and adult social care by only £8 billion in 2024/25. This includes £4.7 billion dedicated to adult social care, which is to be funded by new grant funding, further flexibility for local authorities on council tax and crucially, delaying the rollout of adult social care charging reform, which would have implemented the £86,000 cap on care costs, to October 2025.
176.There is limited information on the exact nature and objectives of the additional funding. The Government has said that:
No announcements were made concerning funding for the reforms set out in the 2021 White Paper.
177.The lack of certainty that has surrounded future funding for adult social care in the past years is a significant impediment to any meaningful change. The Association of Directors of Adult Social Services wrote that recent political and financial uncertainty has left people needing and working in adult social care “in limbo” and with “no plan” at a time of “intense challenges”.
178.Even more importantly, we believe that the current share of Government investment that is dedicated to the sector falls short of what is required to tackle major challenges that are facing services, and in turn failing people and families. The King’s Fund wrote that while the additional funding indicates that the Government recognises the “perilous” state of the sector, “increases to the national living wage, hikes in energy prices and ongoing inflationary pressures will all add to social care providers costs.” This means that it is unclear where the proposals leave local authorities’ finances in real terms.
179.In 2020, the House of Commons Health and Social Care Committee, then chaired by Mr Hunt, recommended as a starting point that social care funding must increase to reach an additional £7 billion in annual funding by 2023/24, compared to 2020/21. Sir Andrew Dilnot similarly recommended that the next Spending Review sets out an increase of at least £2 billion every year for three years, to reach a total £6 billion increase in annual funding. He argued that it is critical that any amount is phased over several years. “Local authorities need reasonable certainty about what they can do,” said Sir Andrew Dilnot; this is not possible if “an extra dollop of money” is allocated at random every year.
180.The Government must increase the financial settlement for adult social care over three years and then commit to sustain realistic, long-term and protected funding for the sector to enable robust planning. Funding requirements over and above what has already been committed should be assessed on the best estimates from independent experts and agencies.
181.The other outstanding issue that is directly related to funding is the lack of paid care workers, which also creates increasing expectations of unpaid carers. Extremely low wages, inflation and the increase in energy and housing costs have created a perfect storm, making it extremely difficult to retain care workers. A recent survey of directors of adult social care services showed 94% of respondents disagreeing that the workforce in their local area will be sufficient to manage over the next few months, making workforce the area that directors are most concerned about. We were told by Laura Gaudion, the director of adult social care and housing needs at the Isle of Wight Council, that: “Yes, cost will always be a pressure; yes, funding will always be an issue; but for me, workforce trumps all that.” She argued that, with the right workforce, equipped with the right skills, motivated by the prospect of supporting people to lead fulfilling lives and paid a fair wage recognising those skills, the outcomes of adult social care will radically improve.
182.The barriers that are holding back the workforce in adult social care are both skills shortages and retention. The current figures, released by Skills for Care show that as of October 2022, there were 165,000 vacant posts in the adult social care sector; an increase of 52% in one year, from what was already the highest rate on record. The average vacancy rate across the sector stands at 10.7%, which is more than twice the average in the wider economy. This deterioration can be explained in part by the COVID-19 pandemic. Monthly data submitted to the CQC by providers of residential care, for instance, show that care home staff vacancy rates have almost doubled from 6% at the end of April 2021, to 11.5% at the end of December 2021, and have since not improved.
183.The CQC told us that “urgent action is needed to tackle staffing pressures and the stresses caused by staff shortages.” The high number of vacancies goes together with a turnover rate of 34.8%—compared to 25.5% in April 2021. Existing estimates of future workforce needs in the sector anticipate that an additional 490,000 people will be needed working in adult social care by 2035; leading the All-Party Parliamentary Group on Adult Social Care to conclude that “we have a massive problem.”
184.In addition to creating higher demand for staff, the COVID-19 pandemic has born down heavily on the mental and physical health of the existing workforce, and was described by the Trades Union Congress (TUC) as “traumatic.” A survey of more than 1,200 care workers carried out between December 2020 and January 2021 identified significant negative mental health impacts on care workers: 75% said that their work during the COVID-19 pandemic had a serious negative impact on their mental health. The TUC added that the negative impacts of the pandemic on care services and workers have continued throughout 2021. Levels of staff sickness nearly doubled over the course of the pandemic, with an average of 9.5 days lost to sickness in 2020/21 compared to 5.1 days before the pandemic. 97% of social care workers surveyed in late 2021 reported that their employers were experiencing workforce shortages, with burnout, overwork and low pay cited as the main causes. All of this has contributed, we were told, to social care staff being at a high risk of burnout.
185.Low pay and sometimes challenging working conditions also contribute to the difficulty of recruiting and retaining care staff. In a snap poll of providers conducted by the CQC in August 2022, many cited pay as having an impact on recruitment and retention of staff. Analysis by the Health Foundation found that in 2019/20 in England, the full-time equivalent mean annual pay rate for staff providing direct care in independent residential care settings was £16,800, compared with £30,400 for all full-time jobs in the UK. The analysis concluded that residential care workers are overall more likely to live in poverty than the average worker, and twice as likely to experience food insecurity. This is made even starker in the context of the cost of living crisis: for example, the higher cost of petrol and diesel is particularly detrimental to homecare staff who rely on a car to get them to visits. Up to 90% of directors of adult social care services agree that there has been an increase in the number of people leaving the social care workforce in their local area as a result of the cost of living crisis.
186.Better funding can partly address issues related to low pay. Nine out of 10 directors of adult social services indicated in a recent survey that the action that would have the largest impact from a workforce perspective would be to increase funding sufficiently to enable pay parity between social care roles and NHS roles, as well as other labour market competition.
187.Adult social care is rarely celebrated as a rewarding and fulfilling career. We were frequently told that adult social care lacks clearly defined career pathways and gateways into more senior roles. Significantly, there is no professional recognition or certification of skills acquired in many adult social care roles. All these factors act as a deterrent.
188.The shortage of social care professionals directly impacts the amount of unmet and under-met needs. According to the CQC, in the first three months of 2022, 2.2 million hours of homecare could not be delivered due to insufficient workforce capacity. The figure is seven times greater than it was in spring 2021 and represents an average of 170,000 hours of homecare not being delivered each week. The CQC spoke of a “social care workforce crisis,” a view shared by 99% of NHS leaders.
189.The Government has acknowledged that reforming the workforce in adult social care is a priority. In the 2021 ‘Build Back Better’ plan, they proposed to make care a more rewarding vocation by offering a career where people could develop new skills. The December 2021 White Paper set out that at least £500 million would be spent on ensuring the social care workforce has the right training and qualifications. This included creating a Knowledge and Skills Framework (KSF) to articulate the knowledge and skills required for roles within the sector and set out clear pathways for career progression. The White Paper also mentioned new budgets for continuous professional development, training routes, and a new digital hub for the workforce to access support and advice. We were told by Gillian Keegan MP, then Minister of State for Care at the Department of Health and Social Care (2021-2022), that the Government is concerned with attracting many more people to working in social care, and that “the reforms will make a massive difference to the visibility and the profile of the role.” The 2022 Autumn Statement, however, has made it unclear whether these reforms will be brought to life in the next few years.
190.What is certain is that nothing strategic can be achieved without an equivalent to the NHS ‘People Plan’, which sets out its workforce strategy and is key to delivering its objectives over the next 10 years. England stands alone in not having developed a similar workforce plan for adult social care. The Scottish Government recently published a five-year ‘Health and social care national workforce strategy’ backed by £1 billion. The Welsh Government’s 10-year workforce strategy for health and social care was published in 2020. Many witnesses pointed to the need for a long-term national workforce plan to meet immediate and future needs, and to address the factors that make adult social care an increasingly unattractive proposition: low pay, difficult working conditions, lack of career structure and lack of status.
191.This requires more than increasing the pool of workers to reduce shortages. It is also necessary to understand what kind of workers will be needed in which roles. The CQC, for example, states that to maintain and develop the workforce, and to plan for the future, it is necessary to review workforce needs for the longer term, including skills sets. For example, in an independent report, Lady Cavendish explains that it is clear that an ageing population will need a different skills mix as demand for geriatricians, community and district nurses will increase. It is necessary, therefore, to anticipate and plan for these new demands. This can only be achieved in partnership with people who have lived experience of the social care system. It is key, therefore, that any workforce strategy is drawn together with people who draw on and work in adult social care.
192.The Government must prioritise, with people who work and draw on adult social care, a comprehensive long-term national workforce and skills plan for adult social care, including a commitment to remedy low pay in the sector.
193.While the fundamental weaknesses of adult social care policy and provision demand priority, they will take time to put right. It is possible, however, to immediately strengthen the voice and identity of the sector, with the objective of creating more energy and advocacy for change.
194.The NHS has “one employer, national terms and conditions for all staff, and a plethora of esteemed institutions including Royal Colleges”. This creates a sense of identity, pride and belonging to the NHS, which the Future Social Care Coalition presented in stark contrast to the situation in adult social care. We discussed in previous chapters how the development of a local and diverse market in adult social care has meant that the sector has never had a unified national focus or profile. There is not one national representative body that acts as a point of reference, advocacy and appeal. There is no way and no one who can speak for the sector, celebrate its purpose and success, or challenge the Government to do better.
195.As the National Care, Support and Independent Living Service (NaCSILS) told us, without one central visible entity, it is difficult to address most social care concerns. Without a unified, central entity, it is more challenging to have a cohesive and organised response to the issues facing the sector, or to hold local providers accountable. Improvements tend to be on a local scale, rather than consistent across the country.
196.In Scotland, this is a challenge that is being addressed by the establishment of a National Care Service. The National Care Service (Scotland) Bill was introduced to the Scottish Parliament in June 2022 and the Scottish Government has committed to creating a functioning National Care Service by the end of this parliamentary term in 2026. With the Bill, the Scottish Government is hoping to ensure that care services are offered in the same way and at the same standard throughout Scotland; and one witness told us that they were confident that the new service will “drive up quality in social care.”
The National Care Service (Scotland) Bill establishes Scotland’s National Care Service. It was introduced by the Scottish Government to improve the quality of social care and social work, and to ensure that people can receive high-quality care services regardless of where they live.
The Bill is rooted in a series of principles:
197.We are not convinced that establishing a National Care Service in England is the most appropriate response to solve the challenges facing adult social care. The local nature, local delivery, local demographics and the local market are key to services, which must meet different situations and needs. Different solutions must be found and one design would not fit all.
198.However, what is missing is a robust, realistic and coherent plan of action. We were frequently told, for example, that adult social care lacks a suitable national long-term plan, which could help bring a cohesive response to the challenges faced by the sector, while raising the profile and voice of adult social care. The Government’s December 2021 White Paper set out a 10-year “vision” for adult social care; but stakeholders agreed that this falls short of a “proper” plan. Mr Hunt, for example, told us:
“You can find words where the Government have claimed they have a 10-year plan for social care. However, I do not really see one. I see plans for the short and medium term, not a really big vision answering questions such as whether we want to keep building more care homes.”
We were told that the White Paper is “a starting point with very much more detail needed to try and operationalise that vision.” For example, the Government’s recent funding announcements have not clearly established that there will be any investment dedicated to the White Paper’s proposals in the next three years.
199.This is again in contrast to the NHS, which in 2019 published a ‘Long-Term Plan’. Although not a panacea, this was described as “enormously beneficial” by Mr Hunt, who argued that it enabled the sector to unite behind a common overarching vision. The Governments of Scotland and Wales have each published a plan for health and social care. On the other hand, in England, one witness described to us that “there is a sense that there is no plan, no north star, and no real clarity about where we want to get to in 10 years and what steps we need to take to get there.”
200.A national plan for adult social care would be bound not only to encompass a comprehensive workforce strategy, but also a national strategy for unpaid carers, the lack of which was described to us as “absolutely appalling”. “We need leadership from Government on this from No 10 downwards,” wrote the We Care Campaign, to ensure that it is heard from senior leaders and resonates nationally.
201.The Government must put in place, with people who work in and draw on adult social care, a national long-term plan for adult social care, exemplifying the vision set out by Social Care Future—“we all want to live in the place we call home, with the people and things we love, in communities where we look out for one another, doing what matters to us.” This should include a National Carers Strategy.
202.Raising the profile of adult social care also means enabling a national conversation about what affects us all as an ageing society—what the role of adult social care is and can become. As discussed in Chapter 3, stigma and discrimination against older adults and disabled people must be challenged, just as the entitlement to choice and control at every stage of life needs to be normalised.
203.While a stronger and more resilient care sector is needed at the local level, we also believe that some new and effective national leadership that focuses attention on adult social care is urgently needed. This would stand above the local and national discourse to represent the real lives, real needs and ambitions of those who value and use care services. With a louder voice and visibility, it could make the case for action and change.
204.Many stakeholders felt that the Government needed to lead on changing public attitudes by “challenging and changing the narrative through legislation and other approaches.” We were told by experts by experience that a representative for the sector at the highest levels of Government is missing, with one unpaid carer saying: “There is no one entity or one person looking after carers. A Carers’ Champion would be brilliant, to hold other people to account.”
205.The NHS has, within Government itself, the role of a Chief Executive, which is currently held by Amanda Pritchard and previously by Sir Simon Stevens, and which has been seen to be “very significant” in recent years. The fragmentary and local delivery of funding and services in adult social care does not lend itself to such an equivalent. But accountability can be delivered through visibility and voice, by having a champion for the social care sector, described to us by Sir Andrew Dilnot as “a single person whose job it is to think or worry about social care and do that publicly.” One effective way of doing so would be to establish a Commissioner for Care and Support, tasked with acting as an effective champion and upholding the rights of disabled adults and older people, as well as unpaid carers. The Commissioner would also embed more accountability and challenge in the system.
206.Such a model already exists for older people in Wales, in the form of the Older People’s Commissioner for Wales, tasked with promoting and protecting the rights of people aged 60 and over. To achieve this, the Older People’s Commissioner was given specific functions and powers in the Commissioner for Older People (Wales) Act 2006. They consist of:
207.In practice, this means that the Commissioner scrutinises and reviews Government announcements and policies that affect older people, for example in relation to care homes or the treatment of older people in hospitals. They can also influence policy and practice by responding to Government consultations, engaging with Welsh Government Ministers, or providing guidance and briefing materials to various stakeholders in adult social care. In 2014, for example, the Commissioner published a report, A Place to Call Home?, which outlined the changes needed in care homes in Wales. In the impact analysis of the report, it was found that this directly led to a range of legislative changes designed to tackle the challenges that were identified, for example with the introduction of a new inspection regime in local authorities that acknowledged the importance of upholding older people’s rights. The Commissioner and their office can also undertake various pieces of legal case work to help individuals with issues such as treatment and care in hospitals and residential care settings, financial disputes, domestic abuse or failure of prosecution.
208.We believe that existing examples powerfully demonstrate the potential benefits of creating a new Commissioner role to uphold the rights and increase the visibility of those drawing on care. We propose the creation of a Commissioner for Care and Support to represent all of those drawing on adult social care, which includes older people, disabled adults and unpaid carers. This Commissioner should undertake the following roles:
209.We are not the first to see the value in the role of a Commissioner. Many Commissioners exist (Information Commissioner, Small Business Commissioner, Children’s Commissioner) with different remits and powers. But there is no one as yet who speaks for adult social care, can identify failure and missed opportunity in the sector, as well as defend and promote social care and everyone affected by it. It is vital that such a role has power to effect and argue for change by holding failure up to the light and revealing the realities of the adult social care system as well as its possibilities. We believe the best way to do this is to take a developmental approach to the Commissioner role, reflecting and developing the powers and duties that are already known to work most effectively and are most likely to empower the Commissioner to bring about tangible change.
210.For a Commissioner for Care and Support to achieve these goals, it is critical that they actively listen to the groups concerned and that lived experience feeds into their work. One way of doing this is to ensure that the role is taken by or shared with someone who has lived experience of the social care system.
211.The Government should establish in the next 12 months a Commissioner for Care and Support to act as a champion for older adults and disabled people and unpaid carers, and to accelerate a more accessible adult social care system. The Government should ensure this role is filled by, or shared in equal measure, with a person who has lived experience.
212.The tragedy of the situation facing adult social care is that the right prescription for many changes have been nearly to hand for eight years in the shape of the Care Act 2014. The Act effectively outlines that the first general duty of a local authority in relation to adult social care is to promote individuals’ wellbeing. Wellbeing is defined as relating to the following:
213.Other general responsibilities of local authorities as outlined in the Act include preventing the development of needs for care and support, promoting the integration of care and support with health services, providing information and advice and promoting diversity and quality in the provision of services.
214.The Act states that where it appears that an adult may have needs for care and support, the local authority must assess what those needs are and how they impact on an individual’s wellbeing; the assessment must also account for the outcomes that the adult wishes to achieve in day-to-day life and the extent to which the provision of care and support could contribute to the achievement of those outcomes. Crucially, the Act also recognises the key role played by unpaid carers. Local authorities must effectively assess unpaid carers when it appears that they may have a need for support. The assessment must include whether the unpaid carer is able to provide unpaid care; whether the carer is willing to carry out unpaid care; the impact of unpaid care on the carer’s wellbeing; the outcomes that the unpaid carer wishes to achieve in day-to-day life and the extent to which support could contribute to achieving those outcomes.
215.In principle, therefore, the Act enshrines in law many of the principles that we endorse for adult social care, including the right for individuals to determine the relationships they wish to have with their families and friends, and the right for unpaid carers to be appropriately supported when they wish to provide unpaid care and support. One witness told us: “What you have is policy and law rooted in a lot of the right stuff. It is rooted in wellbeing, community, choice and control; it puts people in control and at the heart of their care and support.”
216.There is consensus, however, that the Act has never been implemented in practice and has resulted in little change on the ground for older adults and disabled people as well as unpaid carers. Since 2014, the Department of Health and Social Care has commissioned various projects looking at the implementation of the Act and how far it has achieved its aims. While some reported positive progress, for example in the implementation support programme which aimed to assist local authorities to prepare for the changes created by the new law, most found that the impact of the Act has been limited. One report explored the impact of the Act on the support provided to unpaid carers. It concluded that while the Act had increased the recognition of the importance of unpaid carers’ wellbeing at both national and local levels, the challenging financial context has led to a reduction in the support provided to unpaid carers. Unadjusted figures showed that the number of carer assessments in England has declined steadily from 450,000 per year in 2009/10 to just over 350,000 per year in 2017/18.
217.Even the Government admitted in its December 2021 White Paper that “the full spirit of the Care Act is not currently being met.” Throughout our inquiry, we heard that this is reflected on the ground. “There is nothing in the policy that prevents everybody having decent lives but, somehow, it is not happening,” said one expert by experience. As discussed in Chapter 3, the reality of drawing on adult social care for older adults and disabled people, as well as for unpaid carers, illustrates the shortcomings of the Act. Far from ensuring individuals’ wellbeing, care services tend to be reduced to a minimum and designed to enable people to survive, rather than to live and thrive. Choice and control seem to exist mostly in legislation, whether for older adults and disabled people, or for unpaid carers. Many witnesses directly linked the failures of the social care system to the failure to implement the Act, pointing to the “disparities” between the ambitions laid out in the Act and the experiences of practitioners, unpaid carers and people with lived experience on the ground. The challenges faced by the social care sector today were therefore largely attributed to the difficulties that local authorities face to fulfil their duties as outlined in the legislation.
218.The process of assessing individuals’ and unpaid carers’ needs, which is described at length in the Act, is particularly problematic. As stated in the Act, for both individuals with care needs and unpaid carers, an assessment must consider the impact of the person’s needs for support on their wellbeing, as well as the outcomes they wish to achieve in their day-to-day life, and whether the provision of care and support can contribute to achieving these outcomes. Instead, we were told that the assessment of older adults and disabled people often “places the emphasis on what is wrong” in a person’s life. The testimonies we describe in Chapter 3 further illustrate the irrelevance and inappropriateness of assessments.
219.Professor Jerry Tew, who carried out research on the impact of the Act for the Department of Health and Social Care, told us that instead of focusing on what a better life could look like and how to get there, assessments consist of ticking off as many deficits as possible in order to claim services. People feel the need to focus on and emphasise their challenges as much as possible in order to access support that is guarded by strict eligibility criteria. This is a reductive approach that is far removed from the purpose of assessment as outlined in the Act. For many people, it has resulted in assessments being a source of distress. The Strategic Director for Social Care and Education at Leicester City Council, Martin Samuels, recounted how he had realised that people who draw on care services in his local area felt a sense of “dread” and “real concern” when they received paperwork for their annual review, which came out of fear that the system “was going to do something to them.”
220.We heard similar stories from unpaid carers, who described carers’ assessments as a process ranging from irrelevant to intimidating. One unpaid carer told us, referring to the assessment questions related to a carer’s willingness to carry out unpaid care: “If you want a laugh, tell them that, no, you are not willing to be a carer. A social worker always steps over the question and completely ignores it.” Another unpaid carer described how she did not feel listened to and was even “belittled” during assessments, with few examples where the process led to her getting any support.
221.Our attention was drawn to the fact that in some cases, this constitutes a legal failing of local authorities to fulfil their duties. Ms Schwehr pointed to the lack of knowledge that staff might have of their legal duties under the Act, which makes it impossible for them “to understand when they are abiding by the law, when they are sailing a bit close to the wind, and when they are going well over the borderline.” This in turn leads to the rights of older and disabled people, and of unpaid carers, not being implemented in practice. As one unpaid carer told us, carers therefore have rights in principle but rarely in practice. This is also the case for older adults and disabled people.
222.In the December 2021 White Paper, the Government pledged to introduce heightened scrutiny of local authorities’ performance in adult social care, which included a new duty for the CQC to independently review and assess local authority performance in delivering their adult social care duties under Part 1 of the Act. While this change is welcome, the LGA pointed out to us that “things need to be put right first”. Before their performance is assessed, local authorities need to be given the resources to carry out their duties successfully; otherwise closer scrutiny of their activities runs the risk of being an unhelpful exercise. “There is a great danger in labelling all our services with a ‘failure’ tag, which will make the situation worse,” said the LGA. Understanding why the Act has not been implemented in practice and remedying those challenges therefore needs to go hand in hand with the CQC’s future assessments.
223.The tangible explanations for the shortcomings of the Act start and finish with funding. Faced with stretched budgets, local authorities cannot afford to provide services that go beyond minimum support. The charity Rethink Mental Illness argued that the financial context within which the Act was rolled out has contributed to its failure to meet expectations. The Carers Trust also pointed to the insufficient funding provided to local authorities by central government as a key reason that explains why carers’ rights are not met under the Act. Professor Tew explained that, in order for the Act to be implemented effectively, a share of local authority funding and activity should be ringfenced for the promotion and enablement of citizens’ and unpaid carers’ wellbeing.
224.One witness also identified a lack of funding for the training of social workers and for their continuing professional development, which has led to social care staff not being aware of their legal duties under the Act. They told us that this lack of legal training “is like sending a surgeon into an operating room without a scalpel.” They recommended, therefore, that more funding be made available to reform the social work degree course curriculum, with a stronger focus on the legal framework of adult social care.
225.We also heard that, to an extent, the shortcomings of the Act are linked to the cultural issues outlined earlier in this chapter: the Act is an example of a policy change implemented without a cultural change. While the Act embraced the principle of greater autonomy, choice and control, both for those in need of care and unpaid carers, that conviction failed when it came to the greater challenge, described to us by one expert by experience:
“I think the reason why it does not work keeps coming back to how we perceive people’s lives. People think they know what a mental health service user looks like; people think they know what a wheelchair-user’s life is like. We have stereotypical views.”
226.We were also told that, while the Act intended to set out a new vision for adult social care, which came in the form of new duties for local authorities, it did not provide enough guidance and support to assist local authorities in successfully implementing what constitutes a significant cultural shift. Under the Act, some statutory guidance was published to provide local authorities with key information about the obligations placed on them by the Act. This guidance, however, was not seen as sufficient to assist local authorities in generating the significant cultural changes that were required by the Act. Local authorities told us that the radical shifts that were envisioned by the Act should have come with more support and guidance to put these changes into practice. Laura Gaudion, the Director of Adult Social Care and Housing needs at the Isle of Wight Council, said:
“While the Care Act provides us with an overarching vision that is only to be commended in terms of what it delivers for local people, it stops short of providing the support that local authorities needed to change that culture, to shift how things were done.”
227.This is particularly relevant when it comes to understanding the purpose of needs assessments for older adults and disabled people, as well as unpaid carers. Professor Tew highlighted that people should have the right to a needs assessment that is very different to most people’s current experience of assessments. An assessment should denote “a collaborative exploration of what a good life would mean to a person and how this might be achieved,” he wrote, instead of merely establishing a person’s eligibility for services based on narrow criteria. The current guidance falls far short of reconceptualising care assessments in such a way.
228.We do not believe that there is a need for further primary legislation. As one witness told us: “We do not have to reinvent the wheel.” Much of the necessary reform already exists in law; but there is a need for a better understanding of how the Act could be successfully implemented. It is particularly key to reflect on the practical mechanisms that could be provided to local authorities in order to generate a change of culture and embed the Act’s principles in the narrative and delivery of adult social care.
229.The Government must commission an independent public review of the Care Act 2014 and work with local authorities to ensure that the Act is fully implemented by the end of this Parliament. The Commissioner for Care and Support should make it a priority to ensure that the review, update and implementation of the Act happens in practice.
230.With the Care Act 2014 having lain dormant for eight years, it is important that the most recent and radical attempt at the integration of health and social care succeeds. The introduction of integrated care systems (ICSs) under the Health and Social Care Act 2022 has created new opportunities in a way that engages with local disabled adults and older people.
231.ICSs have existed in various forms since 2016, but were formalised as legal entities with statutory powers and responsibilities through the Health and Care Act. There are 42 ICSs covering between 500,000 and 3 million people, that bring together NHS organisations and local authorities, but also other key local stakeholders such as the voluntary, community and social enterprise sector (VCSE) and people who live and work in that area, to take collective responsibility for planning services, improving health and reducing inequalities across geographical areas. They consist of two key components:
232.ICSs have four key aims:
233.The Health and Care Act 2022 also introduced a duty on the CQC to review healthcare and adult social care in each ICB, including looking at how partners in the ICS are working together. This will start in April 2023. ICSs were created with the intention of integrating care, so that different parts of health and social care work in a more joined-up way. Through this, ICSs have the potential to reduce the invisibility of adult social care by creating a more equal footing between adult social care and the NHS, for instance through shared knowledge, a unified voice and cross-sector strategy on issues such as workforce recruitment and retention. COVID-19 has arguably already started this trend, resulting in co-working between the NHS, local authorities and voluntary sector.
234.As part of this, ICSs also have great potential to raise the profile of social care locally; especially with representation from people with lived experience and from carers’ organisations who would ensure that their voices are heard in the design and delivery of services, offering an opportunity for co-production. They could also be held accountable for the quality, range and integration of services.
235.However, there are barriers to integration: England has legally distinct health and social care systems; and the NHS is free at the point of use, while local authorities typically only pay for individual packages of care for adults assessed as having high needs and limited means. We also heard from Mr Hunt that the NHS “will be very reluctant to form big, deep relationships” with social care because of the possible financial liabilities that could come with integration.
236.Integration is an elusive grail. ICSs are one in a long line of attempts to integrate health and social care, for instance through the 2010 Spending Review, the Better Care Fund (2013), the Integrated Care and Support Pioneers Programme (2013) and NHS England’s Five Year Forward View (2014). Further back, we have had Care Trusts, the Health Act flexibilities, Local Area Agreements, Local Strategic Partnerships, Health Action Zones, the New Deal for Communities and many, many more initiatives and mechanisms. One witness therefore expressed scepticism, saying:
“There are at least five pieces of legislation I can think of already which talk about joint working and yet, though a lot is talked about (particularly with ICS), I’m doubtful whether they will work together as long as there are two separate pots of money.”
237.Despite good faith there is a real fear than the NHS will inevitably dominate ICSs. We heard that “any attempts at fostering genuine integration will continue to fail unless greater emphasis is placed on achieving parity between the sectors”. The TUC argued that the lack of funding for social care, the failure to provide a pay uplift for care workers and the lack of ambition of the 2021 White Paper in terms of major system reform place “a serious question mark against the government’s claims that ICSs will be able to bring about greater integration.” Mencap expressed concern that collaboration is based on “better delivering against NHS priorities such as the NHS Mandate rather than against shared health and social care objectives”. They described ICBs as “largely a health body with very little oversight of, or alignment with, the provision of social care.” Ealing Reclaim Social Care Action Group worried that ICSs could even increase the invisibility of social care, with it being “next to impossible for care-users, or their supporters, to influence these mega-bodies”. NHS domination of ICSs could also result in emphasis on the “medical model” of disability (people are disabled by their impairments or differences) rather than the “social model” (disability is caused by the way society is organised).
238.It is vital that adult social care is represented within ICSs to advocate for the sector’s needs and that this includes social care for disabled adults of working age as well as older people. ICSs therefore need to produce a clear strategy on how they plan to engage with adult social care and deliver on its priorities. The voluntary sector must also be included as an equal partner. Encouragingly, this was acknowledged by Jason Yiannikkou, Director of Integration and Legislation, Department of Health and Social Care, who stated:
“There is a profound interdependency between the different services and sectors that the ICS covers, and the importance of drawing in voices from users and carers as part of the development of services has been strongly felt in health as well as in care… this is a moment that I hope we can seize upon.”
239.ICSs also offer a practical opportunity to embed co-production in the design and delivery of adult social care at a local level. This will happen by ensuring that the voice of lived experience is meaningfully represented, heard and included in ICSs. One witness told us that it is crucial to reflect on how older adults and disabled people will be supported to “come to the table as equal partners with the ICSs, local authorities or with other bodies” so that they can have a “civic role” in shaping services and public policy. Unpaid carers should equally be represented in ICSs, and appropriate support should be provided to them if necessary to ensure that they are included. For example, one expert by experience pointed out that unpaid carers may need training and support to participate in local policy making, which should be made available to them. Equally, ICS staff may need training in how to work on a basis of equality and shared power with people who draw on care services.
240.As discussed in written evidence from Chapter 5, the Government’s White Paper includes plans for the CQC to assess local authorities, ICSs and providers using a new single assessment framework, which will be built on principles of co-production. We also heard from civil servants that guidance is currently being designed for ICSs to encourage the representation of different stakeholders. We believe that in addition to guidance, ICSs should ensure that the voice of lived experience is appropriately represented—and so that stated commitment to co-production leads to genuine change, rather than a resurgence of more tokenistic, paternalistic approaches.
241.Despite the potential risks, therefore, ICSs present a significant opportunity to reform adult social care and could be a vehicle for change. It is important that ICSs are designed and function in a way that benefits adult social care—and which seeks to bring formal services together in order to help people achieve the lives they want to lead.
242.For the new ICSs to deliver for adult social care and unpaid carers, the Government must introduce an obligation to include older adults and disabled people, and unpaid carers, in the design and delivery of care; as well as ensure parity between adult social care and healthcare within ICSs.
243.Operating at a local level, ICSs can be expected to develop and invest in place-based solutions to adult social care, which are tailored to the challenges and opportunities that are specific to local communities. For example Nick Sinclair, the Director of the Local Area Coordination (LAC) Network said that he saw ICSs as a key structure to enable the spread of LAC, with local area coordination constituting the “hyper local” reach of each ICS.
244.This has the potential to bring more effective services that are tailored to the needs of all local communities, but our attention was brought in particular to the possible benefits for rural areas. The nature of the care needs of rural residents does not differ from the rest of the population; but we were told that rurality creates “substantial differences” when it comes to meeting these needs.
245.Although differences exist between each rural area, there are common challenges to the delivery of social care outside of urban environments, which need to be taken into account. The first is demographic: older residents are disproportionately represented in rural settings, with 5.8 million residents aged 65 or over currently living in rural areas. This represents 55% of all those in England, a number which continues to grow, and gives rise to more complex and expensive care needs.
246.In parallel, rural areas are faced with significant issues in relation to workforce recruitment and retention; not only because of the smaller proportion of working age population to draw from, but also because of the availability of other, potentially more attractive jobs that are available, particularly in the summer in coastal and tourist areas. This is further aggravated by the lack of affordable housing in rural areas, which contributes to driving working age people to other, less expensive localities.
247.The geography of rural areas also gives rise to specific challenges: providing adult social care in large and remote rural areas means that there is more time and costs involved in delivering care over large distances, a lack of economies of scale and weaker markets. The distance travelled to work is also a key factor in retaining social care staff—even more key, according to models developed by Skills for Care, than contract type and zero-hour contracts. In rural areas, workers travel on average longer distances to work and between jobs compared to urban areas, which, together with the lack of affordable housing, further aggravates the workforce challenges in these localities.
248.The design and delivery of adult social care policy currently does not account for these local characteristics. Witnesses described this as a failure to “rural proof” social care policy, which means examining policies from a rural perspective and adjusting them as needed to ensure that their intended outcomes can be realised in rural areas. Instead, we were told that “we see a one-size-fits-all approach.” This was illustrated in the Government’s pledge as part of the December 2021 White Paper to invest £150 million of additional funding to drive greater adoption of technology and the widespread digitisation of adult social care. The investment, said one witness, is “absolutely useless” without broadband or mobile connectivity, which some rural areas do not have; and by the time they do, it is unlikely that any of the funding will be left to serve them. “What is the rural proofing in that?” they asked.
249.As a result, the provision of care services in rural, remote and coastal areas can be inadequate. An inquiry led in 2022 by the APPG in Rural Health and Social Care found that the provision of services in rural, remote and coastal areas is generally poorer than in more heavily populated parts of the country. For example, access to maternity care is more challenging, as well as to wider community services for children and young people; and the provision of services for the growing proportion of older adults was described as “inadequate”. This highlights the need for locally appropriate approaches. Kate Garner, the Service Manager at Shropshire Council, illustrated this as she told us that delivering centralised services in her local area “does not work” because it would require reaching more than 150 parishes, 18 market towns, as well as smaller towns, villages, hamlets and clusters. Designing and delivering adult social care therefore requires taking a more flexible and creative “locality approach”, which accounts for the strengths and opportunities that exist within the area. We were told that “it is about doing things that matter and supporting the kind of life that people want in those local communities and in the context of those local communities.”
250.We heard that ICSs could play a key role in enabling this “locality approach”. By acting at the local level, ICSs effectively have the potential to rural proof the design and delivery of adult social care. “When the ICSs start to develop their plans, strategies, service commission, and all those sorts of things, the starting point needs to be genuinely to rural proof the needs of those rural communities,” said one witness. The APPG on Rural Health and Care also argued that ICSs will enable a simpler and better coordinated system, which will foster local and place-based flexibility. For example, fostering micro providers, as is the case in Somerset through the Somerset Micro-enterprise programme.
251.To be successful, therefore, ICSs must adopt a sub-regional approach to the design and delivery of care, which will mean understanding the diversity of strengths and challenges that are specific to the area, including within the same locality. This will offer scope to tackle longstanding issues by developing approaches that are more attuned to the needs of local people. It is only based on this locally-appropriate approach that flexible and effective social care services can be designed.
241 Social Care Future, ‘A vision for the future of social care’: [URL updated 3 May 2023]
242 (Tricia Nicoll)
243 Social Care Future, ‘A vision for the future of social care’: [URL updated 3 May 2023]
244 Association of Directors of Adult Social Services, Spring Budget Survey 2022 (19 July 2022), p 9: [accessed 30 September 2022]
245 NHS England, Our 2022/23 business plan (July 2022) p 21: [accessed 16 September 2022]
246 House of Commons Library, Adult social care workforce in England, , 5 September 2022
247 (Jeremy Hunt MP)
248 (David Fothergill)
249 National Audit Office, The adult social care market in England (March 2021) p 6: [accessed 16 September 2022]
250 Health and Social Care Committee, (Third Report, Session 2019–21, HC 206)
251 Written evidence from the Local Government Association ()
252 Written evidence from London Councils ()
253 (Andy McCabe)
254 Written evidence from ADASS (Association of Directors of Adult Social Services) ()
255 Association of Directors of Adult Social Services, Autumn Survey Report 2022 (November 2022) p 14: [accessed 17 November 2022]
256 (Les Billingham)
258 HM Government, Build Back Better: Our Plan for Health and Social Care, CP 506, September 2021, p 16: [accessed 26 September 2022]
259 Department of Health and Social Care, ‘Health and Social Care Levy to raise billions for NHS and social care’ (April 2022): [accessed 30 September 2022]
260 Department of Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, CP 560, December 2021, p 10: [accessed 29 September 2022]
261 Written evidence from the Health Foundation ()
262 Written evidence from the Local Government Association ()
263 (Vic Rayner)
265 HM Treasury, Autumn Statement 2022, CP 751, November 2022, p 26: [accessed 21 November 2022]
267 HM Treasury, Autumn Statement 2022, CP 751, November 2022, p 26: [accessed 21 November 2022]
268 Association of Directors of Adult Social Services, Autumn Survey Report 2022 (November 2022) p 7: [accessed 17 November 2022]
269 The King’s Fund, Press Release: The King’s Fund responds to the Autumn Statement on 17 November 2022: [accessed 17 November 2022]
270 Health and Social Care Committee, (Third Report, Session 2019–21, HC 206) p 37
271 (Sir Andrew Dilnot)
272 Association of Directors of Adult Social Services, Autumn Survey Report 2022 (November 2022) p 4: [accessed 17 November 2022]
273 (Laura Gaudion)
274 Skills for Care, The state of the adult social care sector and workforce in England (October 2022) p 11: [accessed 11 October 2022]
275 Ibid., p 13
276 Written evidence from the Care Quality Commission (
278 Care Quality Commission, The state of health and adult social care in England: 2021/22, HC 724 (October 2022) p 87: [accessed 26 October 2022]
279 (Vic Rayner)
280 Written evidence from the Trades Union Congress ()
282 Written evidence from Skills for Care ( )
283 Written evidence from the Trades Union Congress ()
284 Written evidence from Skills for Care ( )
285 Care Quality Commission, The state of health and adult social care in England: 2021/22, HC 724 (October 2022) p 88: [accessed 26 October 2022]
286 The Health Foundation, The cost of caring: poverty and deprivation among residential care workers in the UK (October 2022) p 8: [accessed 11 October 2022]
287 Ibid., p 9
288 Association of Directors of Adult Social Services, Autumn Survey Report 2022 (November 2022) p 8: [accessed 17 November 2022]
289 Ibid., p 10
290 Written evidence from Sense ()
291 Written evidence from Dimensions ()
292 Care Quality Commission, The state of health and adult social care in England: 2021/22, HC 724 (October 2022) p 35: [accessed 26 October 2022]
293 Ibid., p 85
294 HM Government, Build Back Better: Our Plan for Health and Social Care, CP 506, September 2021, p 19: [accessed 26 September 2022]
295 Department of Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, CP 560, December 2021, p 8: [accessed 29 September 2022]
296 Department of Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, CP 560, December 2021, p 68: [accessed 29 September 2022]
297 (Gillian Keegan MP)
298 NHS England, We Are the NHS: People Plan 2020/21: action for us all (July 2020): [accessed 30 September 2022]
299 Scottish Government Cabinet Secretary for Health and Social Care, Health and social care national workforce strategy (March 2022): [accessed 30 September 2022]
300 Health Education and Improvement Wales, Social Care Wales, A Healthier Wales: Our Workforce Strategy for Health and Social Care (October 2020): [accessed 30 September 2022]
301 Care Quality Commission, The state of health and adult social care in England: 2021/22, HC 724 (October 2022) p 99: [accessed 26 October 2022]
302 Baroness Cavendish of Little Venice, Social care: Independent report by Baroness Cavendish (February 2022) p 37: [accessed 22 November 2022]
303 Written evidence from Future Social Care Coalition ()
305 Written evidence from National Care, Support and Independent Living Service ()
307 (Theresa Shearer)
308 Department of Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, CP 560, December 2021:
309 (Jeremy Hunt MP)
310 (Vicky Davis)
311 NHS England, The NHS Long Term Plan (January 2019): [accessed 30 September 2022]
312 (Jeremy Hunt MP)
313 Scottish Government, Health and Social Care Delivery Plan (December 2016): [accessed 30 September 2022] and Welsh Government, A Healthier Wales: our plan for Health and Social Care (June 2018): [accessed 30 September 2022]
314 (Dr Anna Dixon)
315 Written evidence from the We Care Campaign ()
316 (Katy Styles)
317 (Luke Price)
318 (Katy Styles)
319 (Sir Andrew Dilnot)
322 Commissioner for Older People (Wales) Act 2006,
323 Supplementary written evidence from the Centre for Ageing Better ()
324 Older People’s Commissioner for Wales, A Place to Call Home: Impact and Analysis (January 2018) p 14: [accessed 21 September 2022]
325 Supplementary written evidence from the Centre for Ageing Better ()
326 Care Act 2014,
330 (Ian McCreath)
331 Stephen Peckham et al, Improving choices for care: a strategic research initiative on the implementation of the care act 2014 (May 2020) p 10: [accessed 22 September 2022]
332 Jose-Luis Fernandez et al, Supporting carers following the implementation of the Care Act 2014: eligibility, support and prevention (January 2021) p 14: [accessed 22 September 2022]
333 Department of Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, CP 560, December 2021: [accessed 30 September 2022]
334 (Tricia Nicoll)
335 Written evidence from Rethink Mental Illness ()
336 Written evidence from Daniel Reed ()
337 Written evidence from Wiltshire Centre for Independent Living ()
338 (Professor Jerry Tew)
339 (Martin Samuels)
340 (Norman Phillips)
341 (Helen Spalding)
342 (Belinda Schwehr)
343 Written evidence from Sue Gerrard ()
344 Department of Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, CP 560, December 2021, p 78: [accessed 30 September 2022]
345 (David Fothergill)
347 Written evidence from Rethink Mental Illness ()
348 Written evidence from Carers Trust ()
349 Supplementary written evidence from Professor Jerry Tew ()
350 (Belinda Schwehr)
351 (Tricia Nicoll)
352 Department of Health and Social Care, Care and support statutory guidance (November 2022): [accessed 8 November 2022]
353 (Laura Gaudion)
354 Supplementary written evidence from Professor Jerry Tew ()
355 (Professor Sue Yeandle)
356 The King’s Fund, ‘Integrated care systems explained: making sense of systems, places and neighbourhoods’ (19 August 2022): [accessed 28 September 2022]
357 Health and Care Act 2022,
358 Health and Care Act 2022,
359 The King’s Fund, ‘Integrated care systems explained: making sense of systems, places and neighbourhoods’ (19 August 2022): [accessed 28 September 2022]
360 Health and Care Act 2022,
361 The King’s Fund, ‘Integrated care systems explained: making sense of systems, places and neighbourhoods’ (19 August 2022): [accessed 28 September 2022]
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363 Written evidence from Bristol City Council ()
364 Written evidence from the Local Government Association ()
365 Written evidence from Think Local Act Personal )
366 National Audit Office, Health and social care integration (Session 2016–17, HC 1011), p 5: [accessed 30 September 2022]
367 (Jeremey Hunt MP)
368 National Audit Office, Health and social care integration (Session 2016–17, HC 1011), p 6: [accessed 30 September 2022]
369 Written evidence from Halobletec ()
370 Written evidence from the Trades Union Congress ()
372 Written evidence from Mencap ()
373 Written evidence from Ealing Reclaim Social Care Action Group ()
374 Written evidence from Dimensions ()
375 Written evidence from Care England ()
376 Written evidence from Mencap ()
377 (Jason Yiannikkou)
378 (Vic Rayner)
379 (Fazilet Hadi)
380 Supplementary written evidence from Katy Styles ()
381 (Michelle Dyson)
382 Supplementary written evidence from Nick Sinclair ()
383 (Graham Biggs)
384 Rural Services Network, The State of Care in County & Rural Areas (September 2021) p 8: [accessed 12 October 2022]
385 (Graham Biggs)
388 Skills for Care and Workforce Intelligence, Workforce Intelligence Summary: Rural adult social care workforce information: 2018/2019 (March 2019) p 1: [accessed 17 October 2022]
389 (Graham Biggs)
392 Department of Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, CP 560, December 2021, p 7: [accessed 12 October 2022]
393 (Graham Biggs)
394 APPG Rural Health & Care, Inquiry Overview (February 22) p 4: [accessed 17 October 2022]
395 (Kate Garner)
397 (Graham Biggs)
398 (Graham Biggs)
399 APPG Rural Health & Care, Inquiry Overview (February 2022) p 8: [accessed 17 October 2022]
400 Community Connect, ‘Micro Providers information and advice’: [accessed 1 November 2022]