Adult social care in England

Adult social care is personal care and practical support for adults with physical disabilities, learning disabilities, or physical or mental illnesses, together with support for their carers. The Government’s objectives are to enhance people’s quality of life, delay and reduce the need for care, ensure positive care experiences and safeguard adults from harm. In 2012-13, local authorities provided or commissioned £19 billion worth of individual packages of care and universal care services. In addition, the NHS spent an estimated £2.8 billion in 2011-12 on social care, while the Department for Work and Pensions’ spending on incapacity, disability and injury benefits totalled £28.2 billion in 2012-13. However, publicly funded care makes up only a minority of the total value of care, and this proportion is decreasing. Most care is provided informally by unpaid family, friends and neighbours. In 2012, the Department of Health announced new legislation, the Care Bill,1 designed to rationalise local authorities’ obligations and to introduce new duties based on individual wellbeing. The need for collaboration across all bodies and at all levels

Successful implementation of the Care Act depends on an unprecedented amount of collaboration at every level of government. How well care services meet adults’ needs depends on all parts of the complex system of related public services and forms of support working together. We were pleased to hear of strong joint working between the Department of Health and the Department for Communities and Local Government. But effective joint working is not yet extended to other departments, most notably the Department for Work and Pensions which spends £28.2 billion on incapacity, disability and injury benefits and is reforming the welfare system. For example 2.2 million people have given up work to care, adding costs to the benefits bill and loss of tax revenues to the Government. In introducing Personal Independence Payment, the Department for Work and Pensions expects 600,000 fewer disabled people to receive support towards the additional costs of living with a disability than under Disability Living Allowance. Collaboration is also essential at the local level. Local authorities are sharing and learning from evidence on the ground but sector-led improvement is in its infancy. Costs vary enormously with for example the costs for domiciliary care ranging from £10 per hour to above £20 per hour. We are concerned that the plan to make GPs formally accountable as lead professionals, responsible for coordinating an older person’s care across multiple professions, will not work in practice. We welcome the Departments’ determination to keep a central grip on matters and their recognition of responsibility for the system as a whole. There are clear tensions between the commitment to localisation and the determination to achieve best value across all areas. 1 The Care Act received Royal Assent on 14 May 2014 6 Recommendations: The Department of Health and the Department for Communities and Local Government should expand their effective cooperation to include all relevant government departments, in particular the Department for Work and Pensions. The Departments should set out how they intend to support local authorities, the organisations that represent authorities and the wider adult care sector, including providers and voluntary organisations, to collaborate, share and learn from good practice. They should consider whether and what action they will need to take if efforts to spread best practice are not effective. The need to understand how the system can cope with increasing demand and at the same time implement ambitious changes

The Departments do not know whether the care system can become more efficient and spend less while continuing to absorb the increasing need for care. Need for social care is continually increasing because the people who need it, mostly older and disabled people, are two groups in society that are growing in size. Yet public funding to support these groups is falling with an 8% real terms cut in spending between 2010/11 and 2012/13. This has led local authorities to focus on severe need and reduce its spending on preventative care and support to adults. Local authorities’ cost savings have been achieved by paying lower fees to providers, which has led to very low pay for the care workforce, low skill levels within the workforce, and inevitably poorer levels of service to users. We are concerned to learn that up to 220,000 people working in the care system earn less than the minimum wage. We also learnt that in some localities whilst local authorities might pay private providers £13 an hour, the worker would only earn minimum wage of around £6 per hour. We are concerned that the Departments have not fully addressed the long-term sustainability of the adult social care system and that its policies to drive change (the Care Act and the Better Care Fund) are risky, are not supported with new money, and do not acknowledge the scale of the problem. In 2012-13, local authorities spent between £350 and £640 a year on adult social care services for each person in the local authority area. The Departments believe that the wide variations in costs between local authorities indicate that many can meet financial pressures through local efficiency initiatives and transforming services—but the NAO report concludes that much of this cost variation is not due to inefficiencies but can be explained by social, economic and demographic factors, many of which are either outside a local authority’s control or can only be influenced long term. The Departments acknowledge that they do not know how local authorities will achieve the required efficiencies, but still believe the ambitious objectives of implementing the Care Act and integrating services are achievable. Meanwhile, families are caring for relatives more and more, leading to over 2 million giving up work to care at extra cost to the Government through the benefits bill, and almost all seeing no prospect of their quality of life improving.

The Departments do not have the information and evidence to understand fully the challenges that local authorities face in commissioning and providing adult 7 social care and supporting carers. The Care Act will introduce new duties on local authorities, including a duty to assess carers’ needs and provide support and obligations in respect of those that fund their own care (self-funders). These new duties are being introduced as local authority budgets become increasingly constrained with many local authorities already cutting their social care budgets. The Departments neither understand the scale of some of these challenges nor how much it will cost to implement the changes the Care Act will introduce. The Department of Health acknowledges that it does not know whether some preventative services and lower level interventions are making a difference. We welcome its acceptance that more research is needed to identify the most effective ways of working. Local authorities have little information on the numbers, needs, spending and outcomes of self-funders in their areas, nor the numbers of carers. There are concerns that funders are being charged more to subsidise the publicly funded places. Similarly, there are limited data on how people spend direct payments and the quality of care bought. This makes it difficult for authorities to understand, let alone manage, their local care markets. The Departments acknowledge that there is not yet sufficient transparency over data to enable local authorities to see where their costs are high compared to others.

It may not be feasible for local authorities to implement all the proposed changes to the intended timetable. The Care Act will bring significant changes for local authorities and the Departments accept that the changes present a formidable challenge. The Departments expect to see measurable progress from April 2015 but the timetable is very tight. The Association of Directors of Adult Social Care, representing local authorities is sceptical about whether the changes can be implemented by local authorities, in the timescales expected by the Departments. The Better Care Fund aims to enable innovation and accelerate efficiencies, for example, through integration of care and health services, but planning for its introduction has been slower than expected and evidence shows integration takes time. Recommendations: The Departments should quantify the new burdens the Care Act will introduce for local authorities, establish a realistic timetable given the financial constraints, and acknowledge the limits on the sector’s capacity to absorb the growing need for care with falling public funding. To achieve this they must: • address gaps in evidence, information and evaluation in relation in particular to the effectiveness of preventative services, the needs of and quality of care to self- funders, and spending by direct payment recipients. • take account of the impact that local authorities driving down providers’ fees is having on service quality, the charges to those who fund themselves and use the same care services, and the financial sustainability of providers. • assess the nature, extent, impact and implications of the growing burden on informal carers and the extra cost they place on benefits paid out by the DWP . 8 • assess the scope for local authorities to make further efficiency savings, taking account of both best practice benchmarking of costs and of wider social, economic and demographic trends over which local authorities have little control. • Determine ways to ensure the local authorities do learn from best practice and achieve best value. The Departments should define what progress is expected under the Act by when, how they will measure progress and how they will judge success. For example, to work with greater numbers of self-funders than they have historically, local authorities will need to understand their number and what needs they have, and set up new systems. The Departments should monitor local authorities’ progress and make their expectations clear on what should be achieved in what timescale. The need for oversight arrangements to reflect the overriding importance of quality of care There are continuing risks to quality of care and continuity of services both because of pressures on providers and changing oversight arrangements. We are astonished that up to 220,000 care workers earn less than minimum wage and seemingly little has been done to rectify this, and that around one third are on zero-hours contracts. Around half of local authority directors of adult social care report that cost-saving is putting pressure on the financial sustainability of some private sector providers. The Departments do not know the extent of cross-subsidisation between self-funders and local authority funded users. The Department of Health currently monitors the financial sustainability of the top five providers. From April 2015 the Care Quality Commission will monitor the top 40 or 50 providers and if necessary take action to ensure continuity of care for users. The Commission, which has recently been overhauled, currently lacks the skills to undertake this expanded level of monitoring but the Department of Health is confident the necessary skills will be in place by April 2015. Recommendation: The Department of Health needs to be assured that the Care Quality Commission is adequately prepared and staffed to monitor both the quality of services and the sustainability of providers under the new oversight regime.

Local authorities, who have a duty to safeguard vulnerable adults from abuse and harm, have seen a recent rise in safeguarding referrals. Local authorities have a duty to work with the police, local NHS bodies and other partners to safeguard vulnerable adults from abuse and neglect. Safeguarding referrals recorded by local authorities have risen 13% in the two years since 2011. This increase may reflect increased awareness of abuse or may reflect overstretched resources and pressure within the system. Far too many referrals, 43%, have been substantiated. There has been a tenfold increase in calls to the Care Quality Commission’s whistleblowing helpline and we welcome the creation, under the Care Act, of statutory safeguarding boards. Recommendation: The Department of Health, in conjunction with local authorities, needs to understand why safeguarding referrals are rising, in particular whether this indicates rising levels of abuse, and target its interventions and support to local authorities accordingly. 9 1 Forthcoming changes

The Association of Directors of Adult Social Services told us that the Care Act will require GPs to take on the role of lead professional, or nominate someone to take on the role, to coordinate care services for an individual.18 However, it acknowledged that no part of the system has responsibility over other parts, so GPs have no line management or contractual responsibility for other professionals.19 The Departments told us that GPs will not be financially incentivised to take on this role, and at the time of our hearing evidence of the new model’s effectiveness was limited as it was only being piloted.20 11 Qq 13, 54-55 12 Q 61; C&AG’s Report, figure 18 13 Qq 53-55, 73 14 Qq 1, 5-6, 15 15 Qq 7-8, 119 16 C&AG’s Report, paragraph 2.23 17 Qq 10, 117; C&AG’s Report, paragraph 2.24 18 Qq 47-48 19 Qq 50, 108, 117 20 Qq 50, 53, 93-94, 107 11

The Association of Directors of Adult Social Services told us that collaboration is needed across services beyond health and social care, within both central and local government.21 The impact of welfare reform must be seen in tandem with the implementation of the Care Act. Carers UK told us, for example, that about 2.2 million people have given up work to care.22 The NAO concluded that changes to benefits for adults with disabilities and their carers would put further strain on care users’ ability to pay for their own care and for informal carers to provide support.23 Carers UK told us that changes to housing benefit may mean that when people with disabilities have to move house, their caring relationships could suffer as a result.24

Monitoring and analysis of the cumulative impacts of policy and funding changes on people with care needs and on local areas requires collaboration between departments with local policy responsibilities. However, the NAO concluded that Department for Communities and Local Government’s modelling for its 2013 spending round submission was unreliable because it was based on incomplete information from some departments, in particular from the Department for Work and Pensions.25 The Department for Communities and Local Government acknowledged that its working relationship with the Department for Work and Pensions was not as good as with other departments, and that together they must improve the assessment of the impact of changes to welfare services on the social care system.26

We have previously reported that, for the 2010 spending review, the Department for Communities and Local Government had not assessed the cumulative impact of funding cuts and changes to the funding arrangements on the financial sustainability of local government and the services it provided.27 We recommended that the Department work with other departments to improve its assessment before the next spending review. The Department assured us that for the 2015 spending review it would work with other departments to undertake a full analysis across the range of local government services.28 21 Q 11; C&AG’s Report, paragraph 4 22 Q 21 23 C&AG’s Report, paragraph 19 24 Q 16 25 C&AG’s Report, paragraph 1.32 26 Q 105 27 House of Commons Committee of Public Accounts, Department for Communities and Local Government: Financial sustainability of local authorities, Third Report of Session 2013–14, HC 134, 4 June 2013 28 Q 105-106 12 2 Understanding and making informed decisions

The Department for Communities and Local Government acknowledged that the financial pressures on local authorities are considerable and are powerful incentives to transform the way care and support is delivered.29 The NAO found that in 2012-13 there had been a wide variation in local authority spending per head on adult social care, ranging from £350 to £640 for each person in the local authority area.30 The Departments told us that variations in spending indicated that many local authorities could meet financial pressures through improved efficiency. For example, costs in local authorities for domiciliary care varied from around £10 per hour to above £20 per hour. However, the NAO had concluded that much of this variation is explained by local social, economic and demographic factors, which are either outside a local authority’s control or can only be influenced in the long term.31 The Department for Communities and Local Government told us that they did not know how local authorities would be able to maintain spending on care for adults and improve outcomes, in a situation when needs were increasing but overall public funding was falling.32

Publicly funded care makes up only a minority of the total value of care, and this proportion is decreasing. Most care and support is provided by unpaid informal carers such as family, friends and neighbours, while many adults pay for some or all of their formal care services.33 The NAO found that between 2001 and 2011, the number of informal carers had risen faster than population growth across all regions except London, and that informal carers were undertaking more hours of care per week and were, on average, getting older.34 It reported that support for carers allowed them to maintain their health, employment and quality of life, but that 19% of carers known to local authorities were not in paid work due to their caring responsibilities, and 86% of carers had said that caring had affected their health.35 Carers UK told us that carers were pessimistic about their future quality of life, with some 52% expecting this to have got worse during the next year.36

The Care Act creates a duty on local authorities to undertake a carer’s assessment and meet carers’ eligible need for support.37 The Act is also requires local authorities to assess any adult who appears to need care and support, including self-funders. However, both the Departments and the Association of Directors of Adult Social Services said that the Departments did not understand fully the challenges that local authorities will face in 29 Qq 54-55 30 C&AG’s Report, paragraph 1.35 31 Qq 53, 58, 59; C&AG’s Report, paragraph 1.36 32 Q 52 33 C&AG’s Report, paragraphs 2 and 1.6, and figure 2 34 C&AG’s Report, paragraph 10 35 C&AG’s Report, figure 15 36 Qq 15-16; Care Act 2014, Section 10 37 C&AG’s Report, paragraph 1.7 13 commissioning and providing adult social care and supporting carers, because there was currently limited data on informal carers and self-funders.38 For example, local authorities do not know how many informal carers will come forward for assessment.39 Similarly, there are limited data on how people spend direct payments and the quality of care bought, making it difficult for authorities to manage their local care markets. 40

Local authorities have implemented a range of preventative services to delay or reduce demand for care services and keep adults living independently in their own homes.41 However, the Department of Health acknowledged that it did not know whether preventative services and lower level interventions are making a difference.42 The NAO reported that data on preventative and universal services were poor, making it difficult to assess the scale of change in these services, and therefore the impact on informal carers and self-funders.43 The Department for Health recognised the need for greater research in these areas, and it acknowledged that the lack of evidence on what works and how changes should be implemented was a barrier to integration of health and social care.44

Since 2011-12, most local authorities have voluntarily published annual ‘local accounts’ describing progress in achieving their social care goals, but the NAO reported that these were not yet providing full accountability to the public across local authorities.45 For example, it found that some local accounts did not present a local authority’s shortcomings as well as achievements.46 The Association of Directors of Adult Social Services told us that further information about local authorities’ adult care performance was publicly available through the Health and Social Care Information Centre, and many local authorities also publish information through their scrutiny and other reports.47 The Department for Communities and Local Government acknowledged, however, that there was not yet sufficient transparency over data to enable local authorities to see where their costs were high compared to others.48 38 Qq 8, 67 39 Q 8 40 C&AG’s Report, paragraph 2.28 41 C&AG’s Report, paragraph 2.3 42 Q119 43 C&AG’s Report, paragraph 1.10 44 Qq 81, 119 45 C&AG’s Report, paragraphs 2.37-2.38 46 C&AG’s Report, paragraph 2.38 47 Q 10 48 Qq 68, 72 14 3 Risks, oversight and safeguarding

The Care Quality Commission regulates and inspects care providers against minimum standards of quality and safety. It found that, of the adult social care providers inspected between October 2010 and 31 March 2012, 72% met all essential standards of care. The Care Quality Commission is moving away from an annual inspection regime to a risk- based one, where services rated as requiring improvement or inadequate are inspected more frequently than those with a good or outstanding rating.49

The Department of Health told us that it monitored the financial sustainability of only the five largest providers, together with some more general monitoring of the market in order to identify risks. The Department emphasised that this monitoring was intended to alert government to difficulties with providers so that continuity of care can be ensured for individuals. It said that from April 2015, the Care Quality Commission will take on the responsibility of monitoring the financial sustainability of the most difficult-to-replace providers—those with many users, wide geographical reach, or specialised provision—and that the Commission will be able to require information and data from the top 40 or 50 providers and to take action if necessary.50

We have previously reported that it is hard to know whether the Commission has the resources it needs to operate effectively.51 The Commission’s inspectors are responsible for large and varied portfolios of providers but individual inspectors do not have sufficient support to develop the range of expertise needed. The Department of Health told us that although press reports were correct that the Commission did not yet have the skills required to take on this monitoring role, this was because the Commission had not previously needed those skills; it said it was confident that the Commission would have these skills in place by April 2015.52

The NAO found that in the care home market for older adults, local authorities paid less than the average rate that individuals who pay for their own care were charged, and that directors of adult social care had reported that local authority cost-saving was putting pressure on the financial sustainability of some providers.53 It also found that some providers had cross-subsidised the lower fees paid by local authorities through charging self-funders higher fees.54 The Departments told us that they did not know the extent of cross-subsidisation between self-funders and local authority funded users.55

The Association of Directors of Adult Social Services told us that local authorities did not always consider the profit margins of their suppliers, or the impact that reducing fees 49 C&AG’s Report, paragraph 2.31-2.32 50 Qq 82, 84; C&AG’s Report, paragraph 2.12 51 House of Commons Committee of Public Accounts, The Care Quality Commission: Regulating the quality and safety of health and adult social care, Seventy-eighth Report of Session 2010–12, HC 1779, 30 March 2012 52 Qq 85-86 53 Q 82, C&AG’s Report, paragraph 11 54 C&AG’s Report, paragraph 2.13 55 Qq 63-67 15 paid to providers had on the wages of carers and the quality of the care they provide.56 We heard evidence that in Leeds the authority pays private companies £13 per hour but carers receive only £6 or £7 per hour from them. Also we were concerned about evidence from the NAO that: in 2012 care workers’ median pay was £7.90 per hour; some were not paid for travel time between visits; an estimated 160,000 to 220,000 direct care workers in the UK are paid below the national minimum wage; HM Revenue & Customs had reported that non-compliance with the national minimum wage in the adult social care sector was higher in 2011-12 and 2012-13 than in any year since 2008 and around one third of care workers were on zero-hours contracts.57 The Department for Communities and Local Government told us it was unacceptable for providers to pay below the minimum wage, and that if local authorities found that this was occurring they should challenge the providers concerned and refer them to HM Revenue & Customs.58

We asked the Department of Health how they ensured that users were getting a good quality service even though provider fees are being squeezed. We have previously recommended that the Department should address the gap left by the removal of provider star ratings.59 The Department told us that the Care Quality Commission inspection regime is being overhauled and there will be a new, clearer ratings system for all providers.60

The Department of Health told us that safeguarding vulnerable adults from abuse and neglect remained a significant issue in social care. Local authorities have a duty to work with the police, local NHS bodies and other partners to safeguard vulnerable adults from abuse and neglect. In 2012-13, 109,000 safeguarding referrals were recorded by authorities, 13% more than in 2010-11, and the Department told us that in the twelve months before our hearing 43% of safeguarding referrals had been either fully or partially substantiated. It acknowledged that this is too many and recognised that there is still a lot of work to do to embed the principles that stemmed from the Francis Inquiry into the failings at the Mid Staffordshire Foundation Trust.61 However, the Department was unable to explain why the number of safeguarding referrals has risen, and suggested a variety of possible reasons, including increased awareness of abuse within both the system and amongst the general public, and the overstretched resources and pressure within the system.62

Safeguarding boards exist in many local areas to coordinate safeguarding activities between local authorities and their partners, and the Care Act is likely to make them compulsory.63 We have previously recommended that the Care Quality Commission strengthen its whistleblowing arrangements and that it should re-establish a dedicated 56 Qq 23-45 57 C&AG’s Report, paragraph 2.20 58 Qq 60-61 59 House of Commons Committee of Public Accounts, The Care Quality Commission: Regulating the quality and safety of health and adult social care, Seventy-eighth Report of Session 2010–12, HC 1779, 30 March 2012 60 Q 85 61 Q 87 62 Q 87; C&AG’s Report, paragraph 2.35; Care Act, Section 43 63 Q 87; C&AG’s Report, paragraph 2.36 16 whistleblowing hotline.64 The Department acknowledged that the Commission has a significant role in whistleblowing, and confirmed that the Commission had strengthened its whistleblowing procedures, putting in place a hotline which had seen a tenfold increase in calls in the year and a half prior to our hearing.65 64 House of Commons Committee of Public Accounts, The Care Quality Commission: Regulating the quality and safety of health and adult social care, Seventy-eighth Report of Session 2010–12, HC 1779, 30 March 2012 65 Q 88 17