The legacy of Conservative rule for adult social care

Labour’s return to power last week was greeted with a chorus of welcomes from adult social care organisations in England – along with a chorus of demands of the new government.

Broadly, these were for significant investment in, and reform to, the sector to address issues including unmet need, workforce shortages and inadequate care.

For many, these challenges are the legacy of the Conservatives’ 14-year period in office.

The ‘austerity’ decade

This began with the decade of “austerity” in the 2010s, during which councils’ available budgets fell by 29% in real-terms (source: National Audit Office [NAO]).

While authorities strove to protect adult social care from these cuts, their spending on the service was only marginally higher 2019-20 than 2010-11, after taking account of inflation.

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According to the Association of Directors of Adult Social Services (ADASS), authorities had to make £7.7bn in adult social care savings during the decade to manage increasing demand and cost pressures without extra resource.

One result was a significant fall in the number of people who received long-term care, from 872,520 in 2015-16 to 838,530 in 2019-20 (source: NHS Digital).

These pressures were driven by the expected – an ageing population and growing numbers of people with multiple and complex needs – and the unexpected.

For example, the Supreme Court’s landmark Cheshire West judgment, by widening the definition of a deprivation of liberty, triggered a tenfold increase in councils’ Deprivation of Liberty Safeguards (DoLS) caseloads, from 13,700 in 2013-14 to 137,540 in 2014-15.

Modernising the law

The middle of the decade saw the implementation of the Care Act 2014, unifying and modernising the previous panoply of social care legislation into one statute that made promoting wellbeing and preventing, reducing or delaying need the service’s central missions.

Alongside this, it created rights to support for carers and rights to advocacy for those who would otherwise struggle to participate in key processes, placed councils under a statutory duty to investigate adult safeguarding concerns and sought to improve the transitions process for young people.

Photo: Gary Brigden

However, the legislation’s vision soon ran into the realities of the fiscal constraints and pressures on the service.

To take one example, a study published in 2021 found that assessments of, support for, and spending on carers fell in the years following the act’s implementation – contrary to its intent – because of funding pressures.

Care Act deemed a ‘failure’

Key aspects of the act were not implemented, including rights of appeal against council decisions and the so-called ‘Dilnot’ charging reforms, which were designed to make the means-testing system more generous and cap people’s liabilities for their personal care.

The latter were originally due to be implemented in 2016 and were then delayed until 2020 before being scrapped under Theresa May’s government in 2017 – though not for good (see below).

In its 2021 white paper, People at the Heart of Care, the government concluded that the full spirit of the Care Act had not been realised. A 2022 report by a House of Lords committee went further and declared the legislation a failure.

“Far from ensuring individuals’ wellbeing, care services tend to be reduced to a minimum and designed to enable people to survive, rather than to live and thrive,” it said.

The tragic impact of Covid

The austerity years were followed by the tragedy of Covid-19. This would have always hit social care hard given that people who used the service – older people and those with multiple health conditions – were at particular risk from the disease.

But the impact was compounded in the early stages by government policies to free up 15,000 hospital beds in March 2020 and for care homes to make their full capacity available. This led to many people with asymptomatic Covid being discharged into residential care.

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From March 2020 to April 2021, there were 27,179 more deaths than expected among care home residents, while there were 9,571 excess deaths reported among home care users over a similar timeframe (source: the Health Foundation).

In addition, over 900 care workers lost their lives to Covid up to May 2021, while the workforce was worst hit of all occupational groups by long Covid.

At the same time, many people were left at home without a service, and adult safeguarding concerns were delayed, during lockdowns, worsening unmet need, risks of harm and the strain on unpaid carers.

The devastating impact of the pandemic on adult social care triggered an increased focus on the sector – and apparent recognition of its value – from the Conservative government.

The Tories’ reform agenda

Its first response was the People at the Heart of Care white paper, published in late 2021, which allocated £3.6bn to reviving the Dilnot charging reforms, and a further £1.7bn to assorted other changes designed to improve services, from 2022-25.

These included raising qualification levels and the status of the workforce (£500m); expanding specialist housing for people with care needs (£300m); promoting the digitisation of the sector to improve productivity (£150m); enhancing commissioning (£70m), and supporting carers (£25m).

However, much of this reform agenda subsequently unravelled in the face of the severity of day-to-day pressures on services.

Severe pressures remain

The number of staff vacancies increased by 50% to 164,000 in the year to March 2022, while the number of people on waiting lists for assessments, reviews and care packages grew by 37%, to 542,000, from November 2021 to April 2022.

Meanwhile, there was a 57% rise, to over 13,000, in the number of hospital beds occupied by someone fit for discharge, in the two years to December 2022 (source: the Health Foundation), in part because of social care shortages.

Amid such pressures, council bodies argued that it was all but impossible for them to implement the Dilnot reforms in line with the planned start date of October 2023, given the scale of the changes required. These included:

• Recruiting sufficient practitioners and overhauling systems in order to be able to assess and review many thousands of self-funders coming forward to take advantage of the more generous means-test or be considered for the cap on care costs.
• Upgrading their case management systems in line with revised financial assessment procedures and to track people’s progress towards the cap.

Reforms delayed or shelved

In response, the government pushed the start date of the reforms back by two years, ploughing most of the allocated £3.6bn into shoring up day-to-day social care services, including for children. 

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This was accompanied by giving authorities permission to raise council tax by 3% and the adult social care precept – which is ring-fenced for the sector – by 2% per year, along with additional grant funding, from 2023-25.

Then in July 2023, it shifted £600m of the remaining reform funding into core services, having already halved its investment in workforce development.

The Conservatives also shelved their plan to replace the DoLS, and the use of Court of Protection orders to authorise deprivations of liberty in the community, with a more streamlined system, the Liberty Protection Safeguards (LPS).

This was despite DoLS caseloads having continued to mount, topping 300,000 in 2022-23, with the average case taking 156 days, leaving many thousands of people unlawfully deprived of their liberty.

Impact of increased funding

The resulting increase in government funding for adult social care from 2023-25 has had a definite impact.

Councils budgeted to increase spending on the service by 10% in real terms (£2bn) in 2023-24 and have planned to raise expenditure by 9.2% in real terms (£2.1bn) this year.

This has helped fund two consecutive 10% increases in the national living wage, benefiting tens of thousands of care workers, chiefly in the independent sector.

Along with increased international recruitment, which was promoted by the Conservative government, at least until late last year, this appears to have had an impact on workforce sufficiency.

Skills for Care figures show that the sector vacancy rate fell from 9.9% in March 2023 to 8% in April 2024.

No let up in challenges

However, the extra funding clearly did not solve the challenges facing the sector. At 8%, its vacancy rate was more than double the economy-wide average (3.0% as of autumn 2023, according to the Office for National Statistics).

Waiting lists not only remained high but grew, by 8% to 470,576, from March to August 2023, reported ADASS. And the number of people awaiting discharge from hospital has remained stubbornly around the 13,000 mark, shows NHS England data.

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Meanwhile, the Local Government Association (LGA) has calculated that councils would need an additional £5.1bn in 2026-27 compared with 2023-24 to maintain services at existing levels, because of funding pressures.

Lack of certainty over funding and reform

Unsurprisingly, this has prompted calls for further funding for adult social care. However, the Conservatives also faced criticism for how they resourced the sector, particularly through their reliance on short-term grants, sometimes provided with little notice.

“There are concerns that short-term funding does not support value-for-money decision-making,” said the NAO, in a report on adult social care reform published in November last year. “It can lead to a lack of time to review savings options to make good rather than quick decisions.”

The same NAO report also raised significant concerns about whether the Dilnot charging reforms were deliverable by the revised target date of October 2025.

This was not just because of the amount of work this would involve, but also because the Department of Health and Social Care (DHSC) had disbanded the programme board responsible for overseeing the changes.

Unfunded commitments to charging reform

Both the Conservatives – in their manifesto – and Labour – in media interviews – committed to implementing the charging reforms by October 2025 during the election campaign.

But, as think-tank the Institute for Fiscal Studies (IFS) has pointed out, the outgoing government left no funding to implement the changes, meaning fresh resource would need to be found by the new Labour administration.

This is in addition to all the preparatory work that would need to be carried out by civil servants, councils, IT firms who supply case management systems and care providers.

Unsurprisingly, ADASS concluded the chances of the reforms being implemented in October 2025 were “quite low”.

Labour’s offer on adult social care

The party’s election manifesto was not short of pledges on adult social care. These comprised:

• A programme of reform to create a national care service, underpinned by national standards, delivering consistency of care across the country, ensuring high-quality care and ongoing sustainability, and ensuring providers behave responsibly.
• A principle of ‘home first’ that supports people to live independently for as long as possible.
• Local partnership working between the NHS and social care on hospital discharge.
• An agreement setting fair pay, terms and conditions, and training standards for adult social care workers, following widespread consultation.
• Guaranteeing the rights of care home residents to see their families.
• Asking regulators to assess the role social care workers can play in basic health treatment and monitoring.
• Providing councils with multi-year funding settlements.

Is more austerity on the cards? 

However, while councils will no doubt welcome the predictability of multi-year funding settlements – something also pledged by the Tories – they will have noted, with alarm, the lack of commitment to increase their funding.

This is particularly so in the context of Labour’s pledges not to increase income tax rates, national insurance or VAT and limit borrowing so that public debt is on course to fall as a share of national income over the medium-term.

Based on these pledges, the current state of the public finances and likely increases in the NHS, overseas aid, defence and childcare budgets, the IFS has sketched out possible trajectories for local government funding over the coming years.

Under these, council spending would rise by between 0.4% and 2.5% per year in real terms up to 2028-29, with the even the latter falling well short of what the LGA has calculated that authorities need to stand still over the coming years.

This has led to accusations of authorities facing a further round of austerity – albeit less stringent than that of the 2010s – something that Labour has vigorously rejected.

No funding for fair pay agreement

The party also did not pledge any resource to implement its fair pay agreement for the sector, placing significant question marks against its impact.

The IFS has calculated that, if this involved setting a sector minimum wage that was £1 an hour above the national living wage (NLW), it could cost the public sector about £200m-£360m a year; a £2-an-hour boost could cost £750m-£1.2bn a year.

The party’s other pledges on social care, meanwhile, remain open to significant interpretation.

Questions for Wes Streeting and Stephen Kinnock

For example, what does “a principle of “home first” mean in practice, what will the party do differently to speed up hospital discharge and what will its proposed national standards to drive up care quality amount to?

Health and social care secretary Wes Streeting (credit: Labour Party)

Most significantly of all, what is a national care service?

The new health and social care secretary, Wes Streeting, and minister for care Stephen Kinnock will be expected to provide answers to these questions and address the lack of funding in their plans for adult social care over the coming weeks and months.

It will be through their answers that we will know how different a Labour government will be to its Conservative predecessors.