"No more broken commitments on care: underfunded, unclear, urgently needs reform", say MPs

In a report today the Public Accounts Committee says the pandemic’s “devastating impact on the care sector” has emphasised that “care is not properly funded, lacks transparency and urgently needs reform.”

Governments of all political persuasions have promised social care reform for the past 20 years: “white papers, green papers, consultations, independent reviews and commissions” yet, “reform has not occurred”.

Commitments the Government has previously made to the PAC - to ensure long-term funding is in place; to set out plans for tackling the problems faced by the social care workforce - have not come to pass.

The costs of COVID-19 and the dramatic fall in care home occupancy from around 90% at the start of the pandemic to 80% by February 2021 put many providers at risk of failing, but DHSC has “poor oversight of the system and seems complacent about the risks of local market failure”.

The Government has provided welcome, significant short-term support to help providers through COVID-19 - now the Committee says it is vital that DHSC clearly and in detail “sets out how it will help providers move beyond it”.

The current system “does not work for local authorities or those paying for their own care”. Funding cuts have meant most local authorities pay providers below the costs of care and providers live “hand to mouth”, unable to take the long-term decisions which would improve services.

While information about care quality is available, there is a lack of transparency about what people or local authorities get for the money they spend.

Social care is a “people business” and the long overdue workforce strategy must “tackle low pay, improve career development and tackle unacceptably high turnover. Care workers suffer greatly from a lack of parity with the NHS in terms of pay, conditions and status.”

Meg Hillier MP, Chair of the Committee, said: “Carers, younger and older adults needing care, and home care have seen decades of neglect, and the 1.5 million who work in care deserve much better. The reforms to address this now must include a long-term funding plan that allows local authorities and providers to innovate and improve services. We cannot afford more broken commitments on care.”

PAC report conclusions and recommendations

1. The Government has provided significant short-term support to help providers through COVID-19, it is vital that the Department of Health and Social Care now sets out how it will help providers move beyond it. The costs of COVID-19 and the dramatic fall in care home occupancy from around 90% at the start of the pandemic to 80% by February 2021, puts many providers at risk of failing. In response, the Government provided short-term funding through local authorities and the Infection Control Fund. This support has stabilised the market and kept most providers from falling over. However, the Department does not have a strong grip on the variable levels of support that individual providers received and there have been some reports of providers struggling to access some of the additional funding. Commitments around extra funding and free Personal Protective Equipment (PPE) until the end of March 2022 are welcome, but the Department does not have a roadmap outlining how long extra funding and support will be in place. The Care Quality Commission warns that ongoing support is likely to be required in 2021-22 if care home admissions remain low or costs are inflated.

Recommendation: The Department of Health and Social Care, working with the Ministry of Housing, Communities and Local Government, should assess and outline by July 2021 how much support providers need in the short to medium term to deal with COVID-19 and lower occupancy in care homes.

1. Despite years of promising social care reforms to address longstanding issues, the Department of Health and Social Carehas still not put in place a reform plan.For years this Committee has highlighted the need for reform, and successive governments have failed to deliver. Reforms must counter the historical neglect of unpaid carers and the importance of home care. Too often what efforts there have been have focused on the needs of older adults in care homes, rather than on supporting people in their own homes. The Department says it has a team in place to deliver reforms, but we do not yet know how ambitious these reforms will be. We are heartened that the Department accepts the need for further innovation and acknowledges opportunities around home care. Care policy cuts across many other policy areas and therefore government activity. It remains to be seen whether the government can seize the opportunity to break down silos that can exist across government and finally deliver the comprehensive reforms we need.

Recommendation: The Department of Health and Social Care must set out by the end of 2021 a comprehensive, cross-government reform plan for care; with as much focus on support for carers and supporting people at home as on older adults and care homes.

1. Care provision has suffered from a lack of long-term funding.Local authorities have seen a 29% cut in spending power since 2010-11 and face a hugely difficult job of balancing the books while trying to improve services with less money. The Ministry of Housing, Communities and Local Government’s view is that local government funding is enough. In recent years the government has regularly announced ad-hoc funding increases to prop the system up. This lack of financial certainty has constrained local authorities’ and providers’ ability to plan for the longer-term. Investment in staff training, new accommodation and technological innovation are all areas which have suffered from this lack of certainty. The Department of Health and Social Care agrees that longer-term funding would help but points out that care quality has still been maintained in recent years. Long-term reforms around housing, the workforce, technology and prevention must go hand in hand with clear, long-term funding.

Recommendation: Alongside care reforms the Department of Health and Social Care should publish a multi-year funding settlement by the end of 2021.

1. Three years after promising to produce one, the Department of Health and Social Care still has no workforce strategy or plans to align the care and NHS workforces. The Department has not delivered on its previous promises to this Committee to produce a workforce strategy. The 1.5 million people who work in care deserve much better. The need to better support the social care workforce was brought home to us again by the strength of feeling in the written evidence we received. Social care is a ‘people business’ and a workforce strategy needs to tackle low pay, improve career development and tackle unacceptably high turnover. Care workers suffer greatly from a lack of parity with the NHS in terms of pay, conditions and status. The Department needs to quickly address findings from its research into the role of registered nurses who work in care and make good on its assertion that working in care is a positive choice for nurses.

Recommendation: Alongside care reforms, the Department of Health and Social Care should set out by end 2021 a national strategy for the care workforce which sits alongside the NHS People Plan; identifying skills, training and development across health and care.

1. The Department of Health and Social Care has had poor oversight over local authorities’ provision of care and appears complacent about the risks of local market failure.Despite previous recommendations by this Committee, the Department’s oversight continues to be ineffective. A key failure is its reticence to challenge local authorities who pay providers low rates for care. The Department, via the Care Quality Commission, only collects financial details on around 65 large national providers, which means it does not have a good grasp of how most providers on the ground are faring. The Department maintains it is the responsibility of local authorities to manage their local care markets. It was not until autumn 2020, in response to COVID-19, that the Department began to review local authorities’ contingency plans for winter 2020-21. The proposed Health and Care Bill White Paper introduces new powers, such as giving CQC responsibility to look at local authority commissioning. However, the Department is not sure about the level of support and resource CQC will need for this.

Recommendation: Alongside the proposed Health and Care Bill, the Department of Health and Social Care should set out how it will support Care Quality Commission and local government to carry out their new duties; and ensure there is better readiness for local market failure.

1. Neither local authorities nor people paying for care have access to clear information on what they get for their money. Information about provider quality is often accessible through Care Quality Commission. However, there is a dearth of information about how providers spend the fees they receive from local authorities and individuals. In total, spend on local authority arranged care is around £23 billion a year, and estimates suggest individuals separately pay for around £8.3 billion worth of care. A lack of data means the Department cannot assess if providers offer value for money. Research suggests that people who pay for their own care pay a 41% premium, with decisions made at time of crisis as people try and navigate a confusing market. Provider costs and their financial structures are opaque; individuals and local authorities should not be in the dark as to what they get for their money. The Department has no current plans to increase transparency, and CQC confirmed it has no powers to enforce value for money.

Recommendation: From April 2022, all providers should give clear and comparable information over fee levels and a breakdown of how this money is spent, for example by accommodation, workforce, debt interest and profit.