Recommendations & Conclusions
16 items
2
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
We remain unconvinced as to whether the Department knows if it is achieving value for money from the additional funding going to adult social care. Recent funding for adult social care includes short-term, top-up pots of money in response to crises. In response to emerging pressures in 2022, government awarded …
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We remain unconvinced as to whether the Department knows if it is achieving value for money from the additional funding going to adult social care. Recent funding for adult social care includes short-term, top-up pots of money in response to crises. In response to emerging pressures in 2022, government awarded £1.6 billion to help speed up hospital discharge through the Better Care Fund and £1.1 billion new grant funding to local authorities through the Market Sustainability and Improvement Fund (MSIF). It is troubling that, though MSIF funding is intended to support “tangible improvements” in adult social care, the Department did not quantify by how much the funding has contributed to its three objectives of increased staff pay, increased fee rates paid to providers or reduced waiting times. It remains to be seen whether the new CQC inspection regime, and promised improvements in local commissioning, can provide better assurance that top-up funding is not simply going into provider profits. We are concerned that the Department’s grasp of what it is getting for the £1.6 billion funding to support hospital discharge, is similarly vague. Although ‘supported discharges’ (the number of people being discharged from hospital with a package of care) may well have increased as a result of this funding, it is far from clear whether this represented good value compared with other interventions. Recommendation 2: The Department should write to the Committee alongside its Treasury Minute response to set out how it is assuring itself that each additional fund aimed at supporting adult social care is achieving value for money, including on benefits in relation to costs, for example: 6 Reforming adult social care in England • how much additional capacity it has bought with the discharge funding through the Better Care Fund. • how it will ascertain whether funding for market sustainability and improvement has not just ended up increasing provider profit margins.
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Government response AI summary
The government agrees and states it is undertaking significant assurance of new grant funding by requiring local authorities to report on performance and submit detailed spending plans. It cites increases in fee rates and supported discharges, and ongoing engagement with the CQC regarding provider profit …
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HM Treasury
4
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
Notwithstanding its recent efforts to make adult social care a more attractive career, the Department has still not produced a convincing plan to address the chronic staff shortages in the long-term. Workforce vacancies in adult social remain worryingly high with some places, such as rural areas, particularly affected. In 2022–23, …
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Notwithstanding its recent efforts to make adult social care a more attractive career, the Department has still not produced a convincing plan to address the chronic staff shortages in the long-term. Workforce vacancies in adult social remain worryingly high with some places, such as rural areas, particularly affected. In 2022–23, workforce vacancies exceeded 152,000 (9.9% vacancy rate) despite overseas recruitment of 70,000 staff. Proposed visa restrictions and risks of exploitation raise significant questions about the Department’s reliance on overseas staff in future. Given these significant challenges and numerous, repeated calls for a workforce strategy, we find the white paper’s coverage of the workforce woefully insufficient to the scale of the task. It does not tackle all the significant factors impacting recruitment and retention. For example, there is scant detail on pay. Neither does the white paper provide detail on workforce plans beyond 2025 despite the Department’s forecasts that the number of adult social care jobs will grow by almost one-third by 2035. Once again, we see one approach for the NHS and another for adult social care. While we welcome the Department’s plans to professionalise the workforce, it falls short on providing leadership on pay and ensuring parity of esteem with equivalent NHS roles. Reforming adult social care in England 7 Recommendation 4: In the absence of an NHS style workforce plan, alongside its Treasury Minute response, the Department should write to the Committee setting out how it will lead the sector to identify and address workforce challenges, including: • achieving a sustained reduction in the number of vacancies in the sector (beyond 2025) • addressing the challenges and risks associated with international recruitment • tackling local variations in vacancy rates • addressing issues around disparity with NHS pay • assessing which workforce initiatives are most effective for recruiting and retaining staff.
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Government response AI summary
The government agrees but states it has already published its workforce strategy in 2021 and an updated plan in 2023. It reports a decrease in vacancy rates and highlights existing investments in recruitment, retention, workforce training, and support for ethical international recruitment initiatives.
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HM Treasury
5
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
Long-awaited workforce reforms are way behind schedule and too dependent on a ‘novel’ payment system. We welcome the Department’s launch of the care workforce pathway, which aims to provide consistent career progression for those working in the sector, but we are concerned at the lack of progress on other workforce …
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Long-awaited workforce reforms are way behind schedule and too dependent on a ‘novel’ payment system. We welcome the Department’s launch of the care workforce pathway, which aims to provide consistent career progression for those working in the sector, but we are concerned at the lack of progress on other workforce reforms. At £265 million, they make up the largest budget in the scaled-back system reform portfolio (£729 million). It is alarming that many workforce projects are behind schedule because they depend on delivery of a bespoke payments system to pay suppliers directly. These include the Department’s project to increase the number of regulated professionals and the £136 million flagship project to improve workforce training, originally planned for September 2023. Although the Department assures us that its decision to build a bespoke system was well-evidenced, this ‘difficult’, ‘complex’ and ‘novel’ project is creating a worrying bottleneck and the Department acknowledges that the target date of summer 2024 is already at risk. Recommendation 5: The Department should in its Treasury Minute response to this report: • confirm which of the workforce reform projects depend on this payments system and update us on progress with each; and • update the Committee on progress with the payments system (including any updates to the RAG rating and implementation date) and when it expects the workforce initiatives that depend on it to start to have an impact.
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Government response AI summary
The government agrees and confirms the payment system is on track to start making payments from the end of June 2024 with a phased approach. It will enable claims for qualifications and training from June and commits to update the Committee on fund take-up by …
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HM Treasury
1
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department) and from the Department for Levelling Up, Housing and Communities (DLUHC) about progress in reforming adult social care in England.1
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On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department) and from the Department for Levelling Up, Housing and Communities (DLUHC) about progress in reforming adult social care in England.1
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Government response AI summary
The government agrees and details ongoing work, including new Care Quality Commission assurance of Integrated Care Systems and local authorities, and efforts to improve adult social care data quality, timeliness, and availability through a new data strategy and collection methods.
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HM Treasury
8
Recommendation
Twenty-Second Report - Reforming adult …
Accepted
We asked the Department about how it was measuring the effectiveness of joint working between health and social care in delivering better outcomes for the people they served. We heard that CQC inspections, which were now measuring systems as well as institutions, and a “colossal improvement” in data gave the …
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We asked the Department about how it was measuring the effectiveness of joint working between health and social care in delivering better outcomes for the people they served. We heard that CQC inspections, which were now measuring systems as well as institutions, and a “colossal improvement” in data gave the Department a lot more information than it had had before the COVID-19 pandemic. For example, the Department told us that the metrics it was tracking around the number of care packages and hospital discharge, such as how many discharged patients returned to hospital within 90 days, were the real key performance indicators (KPIs) on how the system was working.13 We shared our concerns that there seemed to be no strategy for pulling together these data and KPIs from across the sector and then publishing it and making it accessible. The Department insisted that CQC inspection was providing transparency and that it published a lot of data.14 We acknowledged that there may be more data published and that aggregate data may be available to the Department and to CQC. However, we challenged on how easy it was for members of the public or MPs to understand this data and use it to compare their area with another comparable area, as it had been with Primary Care Trusts.15 The Department provided written evidence after the session to explain the data it publishes on outcomes for ICSs. However very few, if any, of these metrics directly relate to social care, and it is not clear if ICS performance against these metrics is published. The Department also highlighted that there are specific metrics for integrated care in the Better Care Fund Policy Framework 2023–25, but these are only used to set “ambitions” for local systems, without an assessment of whether or not they were achieved.16 Additional funding for adult social care
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Government response AI summary
The government accepts the recommendation, stating CQC assessments of ICSs and local authorities will be published by Summer 2024 to enable public understanding and comparison of outcomes. They are also improving adult social care data through a new strategy, including better outcomes data collection and …
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HM Treasury
9
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
In recent years, there have been multiple short-term, top-up funding announcements for adult social care in response to crises. In response to emerging pressures in 2022, in the November 2022 Autumn Statement government announced funding of up to £7.5 billion over two years (up to £2.8 billion in 2023–24 and …
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In recent years, there have been multiple short-term, top-up funding announcements for adult social care in response to crises. In response to emerging pressures in 2022, in the November 2022 Autumn Statement government announced funding of up to £7.5 billion over two years (up to £2.8 billion in 2023–24 and up to £4.7 billion in 2024–25) to help stabilise the care sector. This included £2.7 billion of new grant funding: £1.6 billion through the existing Better Care Fund to support hospital discharge and £1.1 billion to local authorities through a new Market Sustainability and Improvement Fund (MSIF) for local authorities to support “tangible improvements” in adult social care.17 Further top-up funding during 2023 included £570 million for the Market Sustainability and Improvement Workforce Fund, and £30 million for urgent and emergency care, announced in July, with a further £10 million top-up for urgent and emergency care announced in September.18
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Government response AI summary
The government agrees and states the recommendation has been implemented, detailing the up to £8.6 billion in additional funding made available over two financial years and its impact. It also describes ongoing assurance and scrutiny of new grant funding to local authorities.
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HM Treasury
10
Recommendation
Twenty-Second Report - Reforming adult …
Accepted
When we asked what the Autumn Statement funding had delivered, the Department told us it had achieved “an awful lot” but acknowledged this was not as much as it had wanted and there was more to come. The Department did not quantify how much the MSIF funding had contributed to …
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When we asked what the Autumn Statement funding had delivered, the Department told us it had achieved “an awful lot” but acknowledged this was not as much as it had wanted and there was more to come. The Department did not quantify how much the MSIF funding had contributed to its three objectives of increased staff pay, increased fee rates paid to providers, or reduced waiting times.19 The Department told us that 85% of local authorities had said they planned to use the money on fee rates and that “a lot” of local authorities had said that average fee rates had gone up by 8.9%, noting that this was 13 Qq 22, 23 14 Qq 25–27 15 Qq 29–31 16 Letter from DHSC to Committee, 1 February 2024 17 Q 10; C&AG’s Report, para 2.7 18 C&AG’s Report, para 2.18 19 C&AG’s Report, para 2.7 12 Reforming adult social care in England above inflation. We heard that, as 70% of care provider spending goes on the workforce, this was a way of putting money into the workforce.20 Yet some care providers were more sceptical about the effectiveness of this top-up funding especially with further increases in the national living wage to come. For example, Care England reported that 84% of care providers said that government funding measures such as MSIF had had ‘no impact’ on their financial sustainability in 2023.21 Bupa Global & UK said that when engaging with local authorities it had become apparent that much of the Market Sustainability and Improvement Workforce Fund, which has similar requirements to MSIF, had been absorbed into central local authority costs, rather than being passed on to providers.22 The Local Government Association noted that much of the additional funding would go on meeting pay and inflationary pressures due to the sector’s higher exposure to costs associated with pay, energy, food and fuel prices.23
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Government response AI summary
The government states the recommendation is implemented, providing figures for £8.6 billion in additional funding that supported an 8.9% average increase in provider fee rates and a 10% increase in supported discharges. They are undertaking significant assurance of grant funding, requiring reporting on performance and …
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HM Treasury
11
Recommendation
Twenty-Second Report - Reforming adult …
Accepted
We asked about the risk of profiteering and how the Department was ensuring that the money it was putting into the system was going to the right places. The Department explained that was mainly down to the quality of commissioning and that, as CQC was now inspecting local authority commissioning, …
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We asked about the risk of profiteering and how the Department was ensuring that the money it was putting into the system was going to the right places. The Department explained that was mainly down to the quality of commissioning and that, as CQC was now inspecting local authority commissioning, it would be getting an overview of how good that commissioning is. DLUHC told us that local authorities were responsible for ensuring that their local markets are working functionally and that they can continue to commission care. The Department pointed out that, as shown in the NAO’s report, provider profits were falling, and said it did not therefore consider there to be a particular risk of providers “creaming off profits”. It said that profits in social care were to be made more on the self-funder side than on local government funded care.24
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Government response AI summary
The government states the recommendation is implemented, referring to £8.6 billion in funding and describing ongoing measures to ensure money goes to the right places and prevent profiteering. These include significant assurance processes for new grant funding, requiring detailed spending plans, and ongoing engagement with …
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HM Treasury
12
Recommendation
Twenty-Second Report - Reforming adult …
Accepted
With regard to additional funding for hospital discharge—£600 million in 2023– 24 and £1 billion in 2024–25—the Department told us that delayed discharges had been consistently lower over the last 6 months than the previous year despite an increase in emergency admissions. The Department said that the best measure of …
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With regard to additional funding for hospital discharge—£600 million in 2023– 24 and £1 billion in 2024–25—the Department told us that delayed discharges had been consistently lower over the last 6 months than the previous year despite an increase in emergency admissions. The Department said that the best measure of whether money had been well spent was “supported discharges” – the number of people being discharged with a package of social care or community care. We heard that supported discharges were 17% higher at the end of December 2023 than December 2022.25 In written evidence, Mencap cautioned that one-off discharge funds like this do not tackle the systemic funding issues facing social care.26
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Government response AI summary
The government states the recommendation is implemented, highlighting £8.6 billion in additional funding for adult social care and discharge over 2023-25, which has supported increased provider fee rates and supported discharges. They are also implementing significant assurance processes for new grant funding and enhancing transparency …
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HM Treasury
18
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
We have repeatedly raised concerns about care workforce shortages. When we reported in 2018, vacancy rates for 2016–17 were 6.6%.38 The vacancy rate has increased since then and, as the NAO reported, in 2022–23 vacancies were 152,000, a rate of 9.9%, despite the recruitment of 70,000 staff from overseas. We …
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We have repeatedly raised concerns about care workforce shortages. When we reported in 2018, vacancy rates for 2016–17 were 6.6%.38 The vacancy rate has increased since then and, as the NAO reported, in 2022–23 vacancies were 152,000, a rate of 9.9%, despite the recruitment of 70,000 staff from overseas. We observed that, although this was lower than the high point of 2021–22, when reported vacancies reached 164,000, this was still way off the 60,000 from 2012–13.39 The Department agreed that vacancies were too high but assured us that things were improving. We heard that monthly figures for November 2023 showed a vacancy rate of 8.4% but the Department acknowledged that these were not as robust as the annual figures.40 When we highlighted regional variation, the Department agreed that rural areas were undoubtedly worse affected and that addressing geographical disparities was a high priority for both its staff and local authorities. The Department noted the challenge that as more young people live in cities and more elderly people live in rural and coastal areas, demand was higher in rural areas but the people to deliver care were in the cities.41
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Government response AI summary
The government agrees and states the recommendation has been implemented, referring to its 2021 workforce strategy and 2023 plan. It highlights ongoing investment in recruitment and retention reforms, including workforce training, pay, and a £15 million investment in 2023-24 for international recruitment initiatives.
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HM Treasury
19
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
In its 2021 white paper, the Department said it expected the number of jobs in adult social care to increase by almost one-third by 2035.42 Given its reliance on overseas workers to date, we asked what percentage of the workforce it expected to come from overseas in future. The Department …
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In its 2021 white paper, the Department said it expected the number of jobs in adult social care to increase by almost one-third by 2035.42 Given its reliance on overseas workers to date, we asked what percentage of the workforce it expected to come from overseas in future. The Department told us that it did not do workforce planning in this way because it was not a public sector workforce but rather a private sector workforce with 18,000 employers.43 We asked whether recent changes in Home Office visa policies that restrict overseas workers from bringing dependents might have an impact on the sector’s ability to recruit from overseas. The Department assured us that it expected to be able to carry on recruiting internationally for people without dependents.44 We also asked about the risks of exploitation and modern slavery through the care sector. For example, the charity Unseen UK reported that its anti-modern slavery and exploitation helpline had seen a 606% increase in care sector cases from 2021 to 2022, and that it expected cases in 2023 to exceed 130. The Department told us that, while it does not have a statutory responsibility for the issue, it recognises the concern, and that it was working with other organisations to minimise the issue.45
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Government response AI summary
The government agrees and states the recommendation has been implemented, referring to its 2021 workforce strategy and 2023 plan. It details investments in recruitment, retention, and international recruitment, including £15 million in 2023-24 for local initiatives, alongside adherence to ethical standards in international recruitment.
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HM Treasury
20
Recommendation
Twenty-Second Report - Reforming adult …
Accepted
Given the significant workforce challenges facing the sector, we asked the Department why it had not produced a workforce strategy, despite repeated calls from the sector and our previous recommendations.46 It told us that it considered the workforce chapter of its 38 Committee of Public Accounts, The adult social care …
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Given the significant workforce challenges facing the sector, we asked the Department why it had not produced a workforce strategy, despite repeated calls from the sector and our previous recommendations.46 It told us that it considered the workforce chapter of its 38 Committee of Public Accounts, The adult social care workforce in England, Thirty-Eighth Report of Session 2017–19, HC 690, 9 May 2018; Comptroller and Auditor General, The adult social care workforce in England, Session 2017–19, HC 714, National Audit Office, 8 February 2018 39 Q 34; C&AG’s Report, para 1.8, Figure 2 40 Qq 16, 33, 34; C&AG’s Report, para 1.8 41 Q 17 42 Department Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, December 2021, white paper, CP 560 43 Q 44 44 Q 46 45 Qq 39–43; RSE0021 46 Q 47; Committee of Public Accounts, Adult Social Care Markets, Seventh Report of Session 2021–22, HC 252, 16 June 2021 16 Reforming adult social care in England white paper to be its workforce strategy, and that it would not be possible to create a strategy similar to that produced for the NHS, as the Department is not the employer of the adult social care workforce.47 The chapter did not set out any detail on plans beyond 2025 and in our view is more a series of high level statements and aspirations.48 We heard from some in the sector, such as Bupa Global & UK, that, while they recognised the importance of creating improved career pathways for the adult social care workforce, the white paper fell short of addressing other key factors affecting recruitment and retention.49 The Nuffield Trust, in written evidence, said the white paper’s efforts “did not amount to a long-term strategy” and described the failure to address low pay as “striking”. It said that its research into workforce reform in other countries identified unintended consequences when moving towards greater recognition and professionalisation without accompanied pay increases.50 Although we acknowledg
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Government response AI summary
The government states the recommendation is implemented, asserting that its 2021 white paper and 2023 'Next Steps' plan serve as its workforce strategy. They highlight ongoing investments in recruitment, retention, professionalisation, workforce training, pay, and international recruitment initiatives, citing a decrease in the overall vacancy …
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HM Treasury
21
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
Care England said there was a widespread sense within the sector that careers in adult social care did not enjoy parity of esteem with the NHS and care workers were not afforded the same level of respect from the Government or across wider society.52 Pay for equivalent roles in adult …
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Care England said there was a widespread sense within the sector that careers in adult social care did not enjoy parity of esteem with the NHS and care workers were not afforded the same level of respect from the Government or across wider society.52 Pay for equivalent roles in adult social care is also lower than in the NHS and Community Integrated Care has reported that it could take more than 20 years before the pay gap is closed.53 Delivering workforce reforms
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Government response AI summary
The government agrees and states the recommendation is implemented, outlining existing and ongoing actions such as published workforce strategies, investment in recruitment/retention reforms, workforce training, the Market Sustainability and Improvement Fund (focused on pay), and £15 million for international recruitment initiatives.
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HM Treasury
22
Recommendation
Twenty-Second Report - Reforming adult …
Accepted
We welcomed the Department’s introduction of a new framework aimed at providing consistent career progression for the social care workforce (the Care Workforce Pathway) in January this year.54 However, we challenged the Department on why it had made so little progress overall on its workforce reforms which, even after scaling …
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We welcomed the Department’s introduction of a new framework aimed at providing consistent career progression for the social care workforce (the Care Workforce Pathway) in January this year.54 However, we challenged the Department on why it had made so little progress overall on its workforce reforms which, even after scaling back, make up £265 million of the £729 million remaining for system reform.55 The Department told us that nearly all the budget goes on training and explained that these training initiatives were, in turn, dependent on the development of a bespoke new payments platform to pay suppliers directly.56 This includes the £136 million project for improving workforce training and development, originally planned for launch in September 2023, and the project to increase the number of regulated professionals, against which there was zero spend in 2022–23.57
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Government response AI summary
The government accepts the recommendation and expects the new payments system to begin making payments from the end of June 2024, enabling employers to claim funding for training courses and the new Level 2 Adult Social Care Certificate qualification. The department will update the Committee …
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HM Treasury
23
Recommendation
Twenty-Second Report - Reforming adult …
Accepted
The Department explained that it had chosen a new payments system because it would be making payments on a scale not dealt with before and had wanted a proper way 47 Q 47 48 Department Health and Social Care, People at the Heart of Care: Adult Social Care Reform White …
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The Department explained that it had chosen a new payments system because it would be making payments on a scale not dealt with before and had wanted a proper way 47 Q 47 48 Department Health and Social Care, People at the Heart of Care: Adult Social Care Reform White Paper, December 2021, white paper, CP 560 49 RSE0023 50 RSE0024 51 Q 49 52 RSE0003 53 RSE0007 54 Qq 49, 50 55 Q 64; C&AG’s Report, Figure 7 56 Qq 64–70 57 Q 65; C&AG’s Report, paras 15, 3.11, Figure 7 Reforming adult social care in England 17 to guard against fraud risk, and assess and process requests that came in.58 We challenged the Department on why it had not simply routed payments through local authorities, given they have good existing connections to providers. The Department told us that not all providers had relationships with local authorities which, it said, had been a problem during the pandemic for getting money directly to providers. It assured us that the business case would have looked at all the different options and that having a direct route to providers had “an efficiency to it” and would provide an option to do that in future, should it be needed.59 In written evidence provided after the session the Department confirmed that it had selected a new digital platform by the NHS Business Services Authority as the preferred option in part because local authorities did not have direct relationships with all care providers in their areas. Other reasons cited were to avoid the potential for inconsistencies in approach to training and distribution of funding, and to make it easier to collect data on the value for money of the training.60
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Government response AI summary
The government accepts the recommendation, stating the new payments system is on track to start making payments from the end of June 2024 for training courses and the Level 2 Adult Social Care Certificate. The department will provide updates on progress and fund take-up by …
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HM Treasury
24
Conclusion
Twenty-Second Report - Reforming adult …
Accepted
When asked when the payments system would be ready, the Department told us that it was aiming for summer 2024 but that delivery was “at risk”. The Department described the system as “difficult”, “complex” and “novel” which, we noted, sent “chills down our spine”.61 The Department has since confirmed that …
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When asked when the payments system would be ready, the Department told us that it was aiming for summer 2024 but that delivery was “at risk”. The Department described the system as “difficult”, “complex” and “novel” which, we noted, sent “chills down our spine”.61 The Department has since confirmed that the payments system is rated ‘amber’, meaning that successful delivery is feasible but there are still significant issues that the Department is addressing.62 Assessing progress with reforms
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Government response AI summary
The government agrees and confirms the payments system is on track to begin making payments from the end of June 2024, with a phased approach for specific funds and qualifications. It commits to updating the Committee on fund take-up before the end of the 2024-25 …
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HM Treasury