Short-termist government adult social care policy is starving the sector of investment and hampering councils’ ability to plan, amid unmet need, high levels of unpaid care and growing demand.
That was the verdict of a report yesterday by the National Audit Office (NAO), which also found the Department of Health and Social Care was unable to assess the quality of services and council commissioning because current accountability and oversight arrangements did not work.
The public spending watchdog said the situation meant the government needed to, as a priority, produce a “cross-funded, long-term funded vision for care”, along with strategies to develop the workforce and accommodation for people with care needs.
Lack of investment
One of the main issues highlighted by the NAO was the impact of short-term – typically one-year – government funding settlements for councils, which lead to a lack of investment and an inability on councils’ part to plan.
Though council net spending on adult social care in 2019-20 was at its highest since 2012-1, the NAO said: “Uncertainty over the long-term sustainability of funding has made it difficult for local authorities to plan how much care, and at what price, they will be able to purchase beyond the current financial year, constraining innovation and investment.”
Uncertainty over future funding made providers reluctant to invest in accommodation for adults with care needs, “with no coordinated, long-term vision across government about how to fund or incentivise the market through mechanisms such as fee rates, housing benefit, grant funding or loans,” the report said.
The government’s short-termism also hampered investment in workforce development. Despite stakeholders identifying the need for central leadership to improve pay and conditions for care workers, and to incentivise improved training and development, the government had not published a workforce development strategy for the sector since 2009.
The failings came in the context of there being high levels of unpaid care, unmet need and growing demand. Carers UK estimated there were 7.3 million carers in England pre-pandemic, while a 2018 survey found a quarter of people aged over 65 said they had some unmet need for an activity of daily living for which they did not receive support. Meanwhile, the DHSC has projected that the total costs of care are projected to roughly double, from 2018-38, for both younger adults and older people because of demographic change.
Accountability and oversight ‘ineffective’
Despite this, the NAO found that the government’s current accountability and oversight arrangements for adult social care were ineffective, meaning the DHSC lacked visibility of, and the powers to tackle, the effectiveness of local authority commissioning and the quality of services.
For example, the NAO said that:
- While the number of adults receiving long-term support arranged by local authorities fell from 873,000 to 839,000 from 2015-16 to 2019-20, the DHSC did not have adequate data to assess how much of this was down to cuts in support, an increase in self-funding or reduced need as a result of investment in prevention.
- The government cannot evaluate spending, return on investment or the extent of additional funding needed because of its reliance on Care Quality Commission inspections and oversight of providers, and on the Adult Social Care Outcomes Framework (ASCOF) dataset, to assess outcomes. The NAO said the framework did not currently cover all local authority responsibilities for care, or focus sufficiently on the well-being and perspectives of people who needed care.
- The DHSC acknowledged that most councils paid home care providers and care homes for older people below a sustainable rate but did not use this to challenge these local authorities.
However, the NAO acknowledged that DHSC had increased its focus on adult social care in response to the pandemic.
For example, providers have had to submit regular data on matters such as their capacity and workforce, in return for obtaining Covid-related funding, while councils also faced stringent reporting requirements on how grants were spent.
The DHSC has also increased its internal capacity, trebling its social care policy team, re-establishing a director-general post with sole responsibility for adult care and setting up specific teams to support and challenge local authorities on Covid-19 issues, the NAO said.
The watchdog also highlighted plans to increase oversight further in the DHSC’s recently published white paper on health and social care. The DHSC said it would increase data collection from providers, including in relation to self-funders, hours and costs of care per person, which it said would improve its understanding the system to inform future policy development.
The white paper also includes plans for a new assurance framework for local authorities, which would ultimately involve the reintroduction of CQC assessments of local authorities’ delivery of their adult social care duties, over a decade after they were scrapped.
‘Urgent reform needed’
The report highlighted the need for the long-awaited reform of the sector and urges the government to “finally” turn its attention to doing so.
“Despite many years of government papers, consultations and reviews, the DHSC has not yet brought forward a reform plan.
“The Covid-19 pandemic has underlined the need to address some of the long-standing issues, such as limited data, workforce investment and the visibility of provider finances, however, it has also delayed promised reforms as the government prioritises the Covid-19 response,” it said.
The NAO said a robust reform plan would need a broad cross-government perspective, making sure that benefits, pensions and taxation policies were aligned with care policy to avoid creating “perverse incentives” that negatively affect choices about care.
The DHSC has committed to bringing forward proposals in 2021.
System ‘unfit for purpose’
Responding to the report, Christina McAnea, UNISON general secretary, said the NAO’s “strongly-worded call for action” was hugely significant.
“Campaigners, politicians and now even government watchdogs want urgent reform, the current privatised, fragmented and largely unregulated system is unfit for purpose.
“It’s a recipe for buck passing, wasted resources and failure to deliver for those who depend on care, unions, employers and organisations from across the political spectrum are demanding an overhaul of the entire sector – there can be no more delay.”
Think-tank the Nuffield Trust said the report illustrated the pre-Covid fragility of social care services, which had been exacerbated by the pandemic.
Deputy director of policy Natasha Curry said: “Organisations providing care are too often paid at or below cost for council-funded clients, with the result that they either turn down council contracts, collapse, or charge people paying for their own care higher fees.
“The impact of this unstable system inevitably falls on care workers and the people receiving care, many of whom struggle to access the essential and high quality services they deserve.
“But the question of reform can no longer just focus on financing the sector, the provider market is not fit for purpose and needs comprehensive reform. We need the sustainable solution promised by the prime minister which moves us beyond the short-term approach which has led to the lack of innovation and accountability in the sector.”