"Credible plan to sustain underfunded care sector needed this year" says PAC

REPORT SUMMARY

The adult social care sector is underfunded, with the care workforce suffering from low pay, low esteem and high turnover of staff.

The care sector is in a precarious state but the Department of Health and Social Care (the Department) has not yet said how it intends to put in place a long-term, sustainable funding regime to meet the ever-increasing demand for care.

The Department does not know whether the ways that local authorities commission care, and the prices they pay providers, are contributing to the problems within the care workforce.

We are not convinced that the lack of regulation within the care sector workforce and the balance of regulation versus a market-based approach, is supporting the care sector to provide the best care possible.

The UK’s departure from the EU is causing uncertainty over how the workforce will be sustained, particularly in areas that are more reliant on non-UK workers.

There is an urgent need to reverse the poor public image that care work has to boost recruitment and retention across the care sector.

We are also concerned that the move to supporting people with substantive and critical care needs only is contributing to growing levels of unmet need for people with moderate care needs. These moderate needs may well grow into substantial or critical needs if support is not given. 

The Department has committed to addressing all these issues through the health and care workforce strategy that it is currently consulting on, and the promised Green Paper on funding of care for older adults.

But given the pressures on the sector, we are concerned that the Department sees the Green Paper as a cure all and underestimates the scale of the challenge.

The Department must ensure that its delivery partner, Skills for Care, is properly supported and funded to implement the workforce strategy.

COMMENT FROM PAC CHAIR MEG HILLIER MP

“Adult social care needs sustainable funding and a stable workforce. The sector is scraping by and without an explicit, long-term plan backed by Government it could soon be on its knees.

“Levels of unmet need are high and rising; short-term funding fixes are a road to nowhere and the ingrained issues that lead to high turnover in the workforce could be compounded by Brexit.

“Government should not content itself with councils’ ability simply to meet the legal minimum for care provision.

“Nor should it seek solace in measures that risk opening a prolonged debate on the challenges facing the sector. Those challenges are already well-documented, clear and pressing.

“We urge Government to publish this year, and then implement, a credible long-term funding plan for care.

“This must go hand-in-hand with financial and other support to improve the recruitment, development and retention of the care workforce.

“Skills for Care summed it up when it described perceptions of care work as a minimum wage sector as ‘a source of national shame’.

“This skilled and vital work transforms people’s lives. It could and should be a source of national pride and we urge Government to give swift and serious consideration to the recommendations set out in our report.”

CONCLUSIONS AND RECOMMENDATIONS

Although the Department recognises that the adult social care sector is under financial pressure and has been for some years, it currently has no credible plans for how care could be sustainably funded. The Department believes that, as all local authorities, with the possible exception of Northamptonshire County Council, appear to be at least fulfilling their minimum statutory duties under the Care Act 2014, the sector is funded adequately at the moment. However, it acknowledges that the sector faces significant financial pressure and requires future investment. We are also concerned about the short-term funding fixes aimed at adult social care which are not sustainable. The Department claims that the Green Paper, promised by July 2018, will address this. There are, however, clear and obvious signs of significant financial stress in the sector now with levels of unmet need high and rising. Only 27% of councils have arrangements in place to monitor unmet need. Despite the Department’s Care Act guidance advising local authorities to have regard to the sector’s own benchmark cost for commissioning homecare, over four-fifths of local authorities are paying below this rate. The Department does not have its own benchmark costs and therefore has no way of knowing whether local authorities, either individually or collectively, are paying enough for homecare. Furthermore, people who pay for their own care home placements are subsidising placements for people who receive local authority-funded care. The Department accepts that local authorities have cut services to people with low to moderate care needs, but does not know whether these reductions will result in more people requiring statutory care services in the future. The Ministry of Housing, Communities and Local Government told us that it had given local authorities access to an extra £9.4 billion of funding, but that this is coming from various sources including council tax rises and the social care precept introduced by local authorities themselves.

Recommendation: The forthcoming Green Paper must not be the start of yet another protracted debate about the future funding of care. The Department should establish quickly the funding local authorities need to commission care at fair prices, to support a workforce of the right size and shape to deliver a sustainable care sector in the long-term. It should publish a credible plan, by the end of 2018, and implement it swiftly.

The Department is not delivering on its overarching responsibility for the care market, despite most providers being dependent on public funds. Two-thirds of care providers’ income comes from taxpayers via local authorities. The Department has overarching responsibility for the care market, requiring oversight and engagement with local authorities and providers to ensure a sustainable market delivering improving outcomes and quality. However, the Department has no means of understanding how well local authorities commission care. We raised concerns that social services and the NHS at local level could end up bidding against each other for beds, and we were told that there were instances of this happening. The Care Quality Commission (CQC) inspects and reports on how well providers deliver care, but it does not routinely inspect local authorities’ commissioning. The Department has confirmed that it is looking at whether it has enough oversight of local authorities’ commissioning and is considering whether to expand the CQC’s current programme of reviews. As we reported in March this year, CQC resources are already stretched. The Department argues that it has few levers to influence the provision of social care, but acknowledges it could use its existing powers more effectively, and that it has not yet developed the right strategy to address how services will meet people’s current and future care needs. 

Recommendation: Within two months the Department should write to the Committee to explain how it intends to:

• respond to the findings of the CQC local system reviews;
• understand how well all local authorities are commissioning care; and
• develop and improve its role overseeing and engaging with the social care market, with the CQC adequately resourced to carry out any further work.

Future immigration policy after leaving the EU will potentially affect the care sector. People from outside the UK are an extremely important part of the care workforce, and their contributions are hugely valued. The Department recognises that the UK’s departure from the EU could have a significant impact on the care workforce and is considering this as one of its four biggest EU workstreams. It is working with the Home Office on taking into account the needs of the care sector as future immigration policy is developed. The Department’s monitoring shows that, to date, the number of non-British EU workers working in care has not yet started to change significantly, but the Department is continuing to monitor the situation. The Department should not be caught unaware if there is a sudden change once the UK leaves the EU. London and southern England are most exposed to the UK’s departure from the EU as these regions have the highest proportions of non-British EU workers. 

Recommendation: The Department needs to understand fully the impact that the UK’s departure from the EU and future immigration policy, could have on the care workforce at both the national and local levels. It should put plans in place to address any shortfalls that might arise, to ensure that there is a sustainable workforce to meet the populations’ future care needs.

Most people working in care are unregulated, which limits the development of a well-trained and professionalised workforce. Currently, the majority of people working in adult social care belong to unregulated professions. The care sector does not have comparable regulation to, for example, the health sector or the construction sector, to mandate skills training. A highly skilled, knowledgeable, qualified and competent workforce leads to higher quality care. Around two-thirds of people in the role of care worker, who provide direct support to people with care needs, have attained the Care Certificate – a basic level of skill and competence – but it is not mandatory. The Department accepts that it will need to be more proactive in ensuring that learning and development occurs, but cautions that regulation carries costs. Some providers may require additional funding to increase the amount they spend on training and development.

Recommendation: The Department should set out in the forthcoming workforce strategy how it intends to professionalise the care workforce further and consider a mandatory minimum standard for training as part of this.

The low amount of funding given to Skills for Care limits the scope and reach of the workforce development initiatives it runs and the extent of its strategic support to the care sector. Skills for Care, the Department’s delivery partner for leadership and workforce development in the care sector, receives £23.5 million per year from the Department, which contrasts markedly with the much greater amount Health Education England receives for support to the health sector. Skills for Care provides welcome and much needed support to the sector to help recruit, retain and develop staff. However, its initiatives are small-scale and limited by the low amount of funding it receives. Turnover of care workers is high and there is not enough support for registered managers Skills for Care is currently consulting on the care aspects of the draft health and care workforce strategy, led overall by Health Education England.

Recommendation: The Department should establish and secure the funding Skills for Care needs both to support the training and development of the care workforce fully and to implement the forthcoming workforce strategy.

The care workforce suffers from low pay and low esteem, which leads to recruitment difficulties for providers. We share the frustration of Skills for Care with the way low pay in the care sector is too often taken to mean low skill. Despite being low paid, care work is not low skilled. Yet care workers and nurses in the sector are not valued in the same way as comparable roles in the health sector, and Skills for Care talked about the need to look at how to achieve greater parity of esteem between the sectors. There is not enough publicity and public recognition of how social care can transform people’s lives for the better, how many people working in care find it very rewarding, or that more than 80% of care services are rated good or excellent by the Care Quality Commission. Instead, care services are usually only in the public eye if something has gone wrong. Skills for Care is developing a national recruitment campaign to address the negative perceptions of working in care.

Recommendation: The Department and Skills for Care should confirm when they will run the national campaign to promote care. They should ensure it is ambitious in scale and scope, seek to change the public narrative around care from overwhelmingly negative to positive, and have senior involvement from the Department.