Covid-19 driving mounting demand and unmet need across adult social care, say directors

Story updated 15 June

Covid-19 has driven increased demand and mounting unmet need due to providers not accepting referrals, service closures and people declining services, a survey directors of adult social services (DASSs) has found.

But despite many more people approaching councils for support, DASSs also warned that there had been a “concerning” fall in domestic abuse and safeguarding referrals in a significant minority of areas with no evidence that such needs had reduced.

The situation risked forcing councils to make significant budget cuts, particularly to preventive services, unless the government stepped in with more cash than it has provided so far to help councils manage the pandemic, warned the Association of Directors of Adult Social Services (ADASS), which carried out the survey.

The survey of the impact of Covid-19 on the sector also raised substantial concerns about the government’s failure to plan for the pandemic’s impact on social care, particularly evident in the drive to discharge rapidly thousands of people from hospitals in March and April.

ADASS president James Bullion said that social care had been left exposed by the pandemic with the government prioritising the NHS, with “tragic consequences” in the deaths of people receiving care.

“The results of the survey paint a vivid picture of the devastating effect of Covid-19 upon millions of us. Those who have died prematurely, those who have had to grieve in isolation, those who have been discharged from hospital without the right assessment, those who have been unable to access community-based services, those who are isolated or shielding, those requiring safeguarding, those experiencing mental health or addiction crises, those experiencing domestic violence, and/or exploitation, and those who work in adult social care.”

Social care left exposed

“The government must ensure that social care is never again left exposed to a pandemic. This starts by protecting those of us with care and support needs from the current and subsequent waves of Covid-19 and extends to ensuring social care is at the centre of all future emergency planning and preparation.”

Looking ahead, Bullion said: “Whilst the wider population may be moving out of the coronavirus peak, Covid-19 will be with older and disabled people for a very long time. Easing the lockdown is about more than opening doors it is about unlocking people’s lives – restoring care and support, assessing needs, preparing for the inevitable surge in demand for care and enabling us all to live our lives again.

“Learning the lessons from the Covid-19 pandemic, the Government must seize the opportunity to reform and reset social care as part of the wider post Covid-19 recovery.”

The survey, responded to by 146 of the 151 directors in England, took place in May following the initial phase of the pandemic and lockdown.

Demand and unmet need hike

The survey found that, overall, there had been an increase in people presenting to adult social services with care needs under the pandemic, driven by the consequences of the lockdown, the need to control infection and the focus on protecting the NHS.

Eighty per cent of directors said they had seen increased need from providers having concerns about accepting new clients – with half saying they had seen need increase by 10% for that reason; 74% had seen increased need from the closure of services, such as day centres, and 71% from people declining services.

In addition, around half of directors reported increased need from care breakdown, sickness and unavailability, people being discharged from hospital and those not being admitted to hospital.

Directors said they had taken steps to address the increased need by enhancing information and advice (90%), retraining other local authority staff to do different roles (87%), using volunteers (85%), making greater use of technology to support people (78%) and shifting capacity between services (69%).

However, almost half reported seeing unmet need increase, with 23% saying it had risen from 1% to 5% and 24% by more than this.

Some of this unmet need remained hidden, warned ADASS, pointing to the 35% of directors who said safeguarding and domestic abuse referrals had fallen, with 42% saying they had increased.

“There is little reason to assume that these needs would have reduced in those areas, rather that people are more reluctant to approach councils, or issues are occurring within domestic settings,” said the ADASS report. “Ultimately it means that some people are not getting the help and support they need.”

Cuts risk

The situation risked forcing councils to make further cuts, particularly to preventive services, warned ADASS, unless the government stumped up more cash to support authorities through the pandemic and beyond.

So far, ministers have provided authorities with £3.2bn in general funding to respond to Covid-19 – an estimated 40% (£1.3bn) of which has been allocated to adult social care – and a £600m infection control fund to help providers control infections, particularly in care homes.

However, an analysis by care market specialists for ADASS and the LGA found that providers could face an extra bill of £5.9bn between April and September of this year from Covid-19, along with reduced revenues of £700m.

“If local authorities don’t get further financial assistance we will have much more significant budget reductions to stay within our much restricted budgets and I’m concerned about our ability to continue to have preventive services while being able to run statutory provision,” warned Cath Roff, joint chair of ADASS’s resources network.

‘Tragic consequences’

The survey reports also highlight significant concerns about how the government has handled the pandemic, prioritising the NHS over social care, with a particular focus on the drive to rapidly discharge people from hospital in late March to free up beds for people with Covid-19. A Department of Health and Social Care document published on 19 March said that people deemed medically fit for discharge should be transferred from hospitals within three hours of the discharge decision, which it anticipated would free up 15,000 beds by 27 March.

While the overall number of discharges from 17 March to 15 April was, at 25,000, significantly lower than the same period in 2019 (35,000), the ADASS report echoed significant concerns about the rapidity of discharges and the fact that, until 15 April, there was no requirement to test those discharged to care homes for Covid-19. Both are implicated in the level of infections – and deaths – in care homes.

Almost a quarter of directors (23%) said they felt over half of infections in care homes in their area were attributable to rapid hospital discharges; 54% disagreed that people were tested on discharge from hospital, 27% that people were discharged to providers without sufficient personal protective equipment and 24% to settings where people could not be isolated safely in order to manage infections.

“We are not saying there was a wilful intention to take infections to care homes but the policy was a significant cause with tragic consequences for individuals,” said Bullion, though he acknowledged that the support for social care providers in managing Covid-19 had improved since the survey was carried out.

The survey also found that the rapidity of discharge led to people not being assessed on leaving hospital and not ending up in the best setting for them. Just two-thirds of directors said everyone in their area was receiving an assessment on discharge, and only 11% said people were being discharged to the right place first time.

“In some areas getting care organised quickly is really challenging, which has led to people having their first choice of care or any choice of care negated because of the need for discharge,” said Bullion.

He added: “If we had thought about social care at the same time as the NHS we would have been able to get a headstart in commissioning.”

He said some areas, included his own county of Norfolk, had set up ‘Nightingales’ for social care – a reference to the makeshift hospitals set up rapidly to create extra capacity for the NHS – and suggested such an approach should have been mandatory.

Provider failure risks

Successive ADASS annual budget reports have raised concerns about the increasing fragility of the care market and the risks of providers failing.

While the latest survey showed an improved position up to the end of March – 24 directors reported home care providers in their area closing or ceasing trading in 2019-20, compared with 72 in 2018-19, and 37 saying the same regarding care homes down from 52 – directors’ concerns have heightened since.

This is particularly true in relation to care homes, with a third of directors now concerned about the financial sustainability of some or all of their providers. Eighteen per cent said the same about home care providers.

Roff pointed to the risks to the care home market from people opting not to make use of them and the impact of high death rates on occupancy levels.

“We are already seeing a quite significant drop in people going into residential care,” she said. “Unless we see a vaccine or effective treatment for Covid, families will choose care at home and that will have an impact on the residential sector.”

She said this necessitated greater investment in alternatives to care homes, such as extra care housing.

Picking up themes from a recent interview with Community Care, Bullion called for the government to develop a strategy to promote social care’s role in the economy and as an employer, including consideration of a national care wage, at a level greater than the current minimum wage.

“If we leave the market to itself, we might see an uncontrolled restructure and we perhaps need a stronger framework for that,” he added.