Last year we listed the key problems as:
- means testing: social care is not free at point of use like the NHS
- catastrophic costs: some people end up paying large amounts and even selling their homes to pay for care
- unmet need: many people go without the care and support they need
- quality of care: a wide spectrum of concerns, from 15-minute care visits to neglect and lack of choice and control
- workforce pay and conditions: staff are underpaid, leading to high vacancy rates and turnover
- market fragility: care providers go out of business or hand back contracts
- disjointed care: health and care is not integrated around the individual and causes issues such as delayed transfers of care from hospital
- the ‘postcode lottery’: there is unwarranted variation between places in access to care and its quality.
In this long read we revisit these eight problems in the light of the Covid-19 pandemic. The emphasis on them has shifted – the first two issues have barely been mentioned during the past few months. Instead, the public focus has rightly been, first, on quality of care, as Covid-19 wrought a terrible death toll and, in many places, fundamentally changed the way care was being delivered. Second, there has also been some, though arguably not enough, focus on unmet need, as Covid-19 both created more need and made it more difficult to meet existing need. A third key area during the pandemic – though one that has had less attention – has been the difference in the ways local care systems have dealt with the pandemic and the potential consequences for the existing postcode lottery of access and provision. Two more areas that have been highlighted during the pandemic have been the sector’s workforce, which has received more recognition than ever before, and to its providers, where the pandemic has exacerbated market fragility. And finally, the relationships between services – which even under normal circumstances can lead to disjointed care – have been to the fore during Covid-19, most obviously in the ongoing dispute about discharge from hospital during the early stages of the pandemic.
Quality of care
Covid-19 has had a huge, tragic impact on quality of care and also affected it in other, less obvious ways.
It is on quality of care that Covid-19 has had the most devastating consequences. Keeping people safe is a primary duty of care and the responsibility of everyone working in social care. Though providers are on the front line, the work and behaviour of regulators, commissioners, policy-makers and partner organisations, particularly in health, has a big impact on what they can do. Quality is therefore a joint responsibility.
Yet, deaths have occurred on a scale that was unthinkable before – and even in the early stages of – the pandemic. By mid-June there had been nearly 30,000 excess deaths in care homes in England and Wales. There have also been more than 3,500 excess deaths among people receiving domiciliary care, although fewer of these are attributed directly to Covid-19. As in the wider population, in care settings people from minority ethnic groups were more likely to die with Covid-19 than white people. The emotional toll on staff in care homes, some of whom lost several residents in a matter of days, is immense. The factors affecting infections and deaths in care homes are already being explored and will be critical learning for any future waves. There is also wide knowledge to be gained from other countries’ experiences. More widely, there are tough questions about the preparedness and resilience of the sector for the epidemic.
But the death toll is not the only issue affecting quality of care. Reduced staff availability (sickness absence tripled to 8 per cent in the early stages of the pandemic), lack of personal protective equipment (PPE) and other factors affected quality and availability across social care, at least in the initial stages of the pandemic (and also had a big impact on service users’ access to the health services).
And quality issues go even wider than this, with potentially long-term consequences. In the urgent rush to clear acute hospitals, some people have been discharged from hospital to services that don’t fully meet their needs – one in five directors of adult social services believed that in general people were not discharged to the right place during the period of rapid discharge from hospital in the initial stages of the pandemic. This may have left some people without, for example, the reablement services that might help them regain their independence. People living in care homes found their ability to leave or move around their homes restricted in the interests of infection control (although some homes went to heroic lengths to maintain activities). Family visits were suspended (or sometimes replaced by technology), as the sector and the government struggled to balance the risk of the virus with potential impact on residents’ mental health (also an issue for the large numbers forced to ‘shield’ in their own homes). Routine Care Quality Commission (CQC) inspections were abandoned with only a very small number of intelligence- and risk-based inspections – arising from the previous history of services or new concerns raised – carried out during the pandemic.
Covid-19 increased unmet need for social care, at least in the early stages of the pandemic, but we can’t yet judge the extent of that change.
Covid-19 will also have affected the level of unmet need for social care, though the picture is a complicated one, with the pandemic both increasing need but also helping to identify it: just under half of directors of adult social services said they believe there has been an increase in unmet need since March 2020.
One factor contributing to increasing need was changes to services, especially during the initial phases of the pandemic. Some people will have had services reduced as providers tried to ensure the most critical care was provided at a time when many care staff were unable to work. Other services – particularly some care homes – closed temporarily to new clients: directors of adult social services report more than 8 in 10 providers concerned about taking on new clients. Some services simply couldn’t operate at all with the restrictions placed on them and closed permanently: for example, the Age UK Essex Home Help Service, which closed because it could not guarantee the safety of staff or clients. Other services, such as day centres, have been suspended as a result of social distancing rules. Many charities report having to scale back services.
The number of people affected by these changes is hard to quantify and estimates vary significantly. A Mencap survey in July 2020 found two-thirds of family members said the amount of social care support received from the local authority had fallen ‘a lot’ compared to the amount received before the Covid-19 pandemic, while Parkinson’s UK found that nearly half of people receiving paid social care, both privately funded and council-funded, had seen a reduction in social care support. A similar MS Society survey put this at just under one in five people. Some people employing personal assistants have talked of feeling abandoned by the system, left without PPE and advice (though a chink of light has been a willingness by some councils at least to give greater freedom in the use of direct payments).
Need will also have risen because of changes in behaviour. Most local authorities report people declining care because of understandable concerns about admitting careworkers into their homes. The CQC found that admissions to care homes fell by more than a quarter among publicly funded clients and by two-thirds among self-funders. Use of home care also fell, though the CQC reports it recovering to 94 per cent of pre-Covid levels by July. It is also likely that many people did not even ask for support for the same reasons they did not go to accident and emergency – reluctance to use services and, perhaps, concern about adding to the huge existing pressure on the system. All of this will have increased the responsibilities of unpaid family carers and created many more of them – Carers UK estimates there are 4.5 million people new to caring since the start of the pandemic, 2.8 million of whom are juggling work and care.
Other aspects of Covid-19 created extra types of demand for local authorities, who reported an increase in referrals to them, generated, at least in part, by their role in local support systems for people shielding or otherwise particularly vulnerable to Covid-19. Some of this demand related to breakdowns of other services, for example, people whose personal assistants were unable to work. Directors of adult social services also reported increased demand as hospitals urgently discharged patients, while demand was also created because other people were unable to go into hospital in the first place. There were also increases in demand from people sleeping rough and because of carer breakdown.
To meet some of this increased demand local authorities have drawn on some positive outcomes of Covid-19: the new networks of neighbourhood mutual aid groups that emerged in many areas to support people and the existing deep roots of many voluntary and community sector organisations. A key question may be how to maintain and build on these networks. Councils also adapted services by enhancing their information and advice offer, re-training council staff, using more volunteers and making increased use of digital technology.
The first months of the Covid-19 pandemic have demonstrated that a consequence of social care’s hugely diverse, independent provision – and of a longstanding national failure to get to grips with that structure – is a paucity of quality and timely service data and intelligence. Though there was some urgent action during the crisis to require care homes and home care agencies to provide basic data on capacity and other issues, this is just scratching at the surface of a much wider data problem in social care, especially since there is not just diversity of provision but also commissioning, with 150 different local authorities. Even basic data on the number of new requests for social care support to local authorities, local authority expenditure and the number of people who received support will not be available until autumn 2021 (when returns for the financial year beginning April 2020 are published). This is surely too long to wait to understand the ‘new baseline’ of social care in England.
The postcode lottery
Covid-19 may well have worsened the postcode lottery of access to social care but we don’t have the data to know for sure.
Even when that data on issues such as requests for support, local authority expenditure and the number of people who received support is available, it will be a tough task to untangle it. Before the Covid-19 pandemic, there was already significant local variation in access to care and service provision. Much of this variation is unexplained and unwarranted – a postcode lottery – while some reflects differences in demographics or strategic policy decisions by local authorities (a ‘postcode choice’).
In a similar way, there was wide variation in the reported experience of local authorities in the early stages of Covid-19. For example, while most directors reported an increase in referrals from the community, a third saw a fall in demand of up to 10 per cent. Similarly, while most saw an increase in need as a result of hospital discharge, 1 in 5 saw a fall.
Overall, it is possible that the extraordinary circumstances of Covid-19 will have increased rather than reduced the differences between local authorities, as they decided how best to respond. Only eight took up the formal powers to ‘ease’ their formal Care Act duties, thereby allowing them, for example, to cease formal assessments. However most, if not all, revised procedures and services with their own individual mix of adaptation – including greater use of volunteers, information and advice – and technology, along with retraining and redeploying staff (for example, from closed day services). Working out what was done by different councils and the impact these actions had will be a difficult task.
Local authorities will also face different levels of challenge in supporting their care markets. The overall number of admissions has fallen but there is wide variation, with admissions funded by local authorities ranging from 43 per cent of 2019 levels in some places to 113 per cent in others, while self-funded admissions ranged from 25 per cent to 51 per cent of 2019 levels. The CQC observes that this could put added financial pressure on homes that are more reliant on people who fund their own care.
There is also apparent local variation in the extent to which local authorities have offered support to providers. In April, the UK Home Care Association was threatening to ‘name and shame’ councils that did not pass on £1.6 billion of central government funding to providers and says there is still ‘huge’ variation. Care England also told us there continues to be large variations in the ways by which LAs are supporting adult social care providers: ‘Many LAs [local authorities] have offered support which doesn't match by any means the unprecedented costs leveraged upon providers as a result of Covid-19.’
Workforce pay and conditions
Covid-19 highlighted the inadequate workforce pay and conditions experienced by social care staff, though it has not as yet brought any improvement in them. And though the clamour for better pay for staff is now relatively strong, there is no guarantee it will last: recessions normally increase the number of people willing to work in the sector and may bring short-term relief to vacancy rates (which are now below those experienced before to the pandemic) but the question of improving pay remains key to improving recruitment and retention in the medium term. Again, there are small positive signs: the government seems now to accept the need to tackle these issues, rather than leave them entirely to the market, and there have been efforts to provide central training support to, for example, registered managers. However, these are all tentative steps, rather than the giant stride forward the sector needs.
Covid-19 has shaken the market, especially for residential care, and seems certain to result in the loss of some providers.
Better staff pay without more funding to pay for it would, however, create fresh problems for the sector’s employers. Care providers already need to fund this year’s 6.2 per cent increase in the National Minimum Wage and Covid-19 has brought new challenges to an already fragile market. However, during Covid-19 some providers have reported that local authorities have adopted less restrictive commissioning practices, and central government money being dispensed to local government to support providers has provided short-term relief in some areas. However, concern remains about the extra costs providers face for extra staffing and PPE. A Local Government Association/LaingBuisson report estimates total extra costs of more than £6 billion for extra staffing, cleaning and PPE, at a time when there is less demand (and therefore revenue). Care homes in particular are struggling with lower occupancy as a result of deaths and reduced demand. A survey of care homes by the National Care Association, which represents smaller and medium-sized homes, found average occupancy at 81 per cent compared to 92 per cent at the same time in 2019. It’s not clear when and to what extent demand will return, and how many providers might fail in the meantime. One recent report suggests the homes most at risk are the 6,500 with fewer than 40 rooms, half of which have outdated facilities.
The public was concerned about care homes before the epidemic and then shocked by the scale of the tragedy that unfolded within them during Covid-19. The sector needs to take clear steps to reassure the public about safety and quality. Yet the reality is that, while we need to see wider availability and choice of services and care settings, including expansion of extra-care, residential care will remain an essential part of that mix for the foreseeable future.
Covid-19 brought rapid, but enormously controversial, change in hospital discharge, with ongoing concern about its immediate and longer-term consequences.
On one level, the response to Covid-19 resolved at speed one of the issues around disjointed care that had bedevilled the sector – delayed transfers of care. The emergency procedures introduced as Covid-19 loomed freed up beds in hospitals in days. Yet the move has proved enormously controversial, with an ongoing blame game about the extent to which the practice of discharging patients into care homes without testing them for Covid-19 contributed to the infection and death rate in those homes. The Public Accounts Committee found that 25,000 people were discharged from hospital to care homes before the introduction of routine pre-discharge testing in mid-April and described this as ‘reckless’. There must be questions about the extent to which this bitter controversy has caused ongoing damage in some areas to critical relationships between providers, NHS organisations and local authorities.
There was also a far less important, but nonetheless significant, financial cost to this action, with the NHS temporarily picking up the bill for people discharged into care services. This may lead to longer-term issues, especially for people whose care is publicly funded, with local authorities concerned about their long-term liability for possibly inflated fees, negotiated in a rush. Directors of social services report that in 38 per cent of councils the rates used were higher than the normal local authority or clinical commissioning group rate.
There is also concern about whether people were always discharged to the right place for their longer-term health and wellbeing. Only two-thirds of directors reported that every person discharged from hospital in their area is getting an assessment during discharge-to-assess processes, and only 11 per cent believed everyone was discharged to the right place. This, says ADASS, could mean people ‘were discharged to a care home when they could have been at home, were discharged to somewhere a long way from family, were discharged to a home that didn’t have the staffing for reablement or other reasons, all of which would have negative impacts on their health and wellbeing’.
Means testing and catastrophic costs
Covid-19 has had limited impact on means testing and catastrophic costs but they remain central to future social care reform.
Two problems we identified in 2019 were less affected by Covid-19, though neither is entirely unchanged.
Social care is still on a different plane (it sometimes feels like a different planet) to the NHS because access involves means testing rather than services free at the point of need. And, irrespective of Covid-19, that means test has been getting progressively meaner. People still pay for all their own care if they have £23,250 of assets, just as in 2010. A decade’s worth of inflation has been ignored. And those who do have to pay for themselves may well face higher fees as providers struggle to cover the increased costs and lower income the Covid-19 pandemic has caused. They may even find themselves subsidising even more of the cost of publicly funded clients.
Means-testing creates an unlucky group of people who not only must pay for their own care but end up needing a lot of it, typically in a care home with dementia. They can easily face lifetime fees of more than £100,000 – ‘catastrophic costs’. Again Covid-19 has not changed the fundamentals of this but it has made some mark. On the other hand, tragically, the appalling death toll in care homes will mean fewer people will have lived long enough to face catastrophic costs.
Underlying issues: funding, reputation and leadership
The extent to which social care deals with how these eight problems and how they have evolved as a result of Covid-19 will depend on a range of factors, most obviously and inevitably funding. There are real concerns not just about the extent of the increased demands on local authority resources but also the impact on the revenues used to meet them. The amount of support provided by central government to local government generally and to social care specifically will be of immense importance, particularly as the sector goes into the period preceding a three-year spending review.
However, in addition to funding, Covid-19 also highlighted linked, underpinning factors around reputation and leadership that may make it harder for the sector to tackle these problems alone.
There have never been as many media stories about social care as there have been in recent months but coverage has focused overwhelmingly on care homes, threatening to reaffirm the widespread misconceptions that social care is synonymous with care homes and with older people. There has been far less coverage, for example, of the much higher death rates of people with a learning disability during the pandemic or the severe impact of Covid-19 on the most disabled working-age adults. And it has been particularly hard to see any focus on central issues such as choice, personalisation and independence amid all the smoke and fire generated by Covid-19.
That coverage has typically also been characterised by polar opposite images: on the one hand, applause and recognition of care and support staff as ‘key workers’ while, on the other, lack of PPE, testing and the deaths of service users. It is by no means guaranteed that the positive image will stick with the public rather than the negative one. As we have seen, this has had immediate consequences for the viability of some of the sector’s businesses, and that in turn means consequences for the people using their services. While some have little sympathy for the fate of privately run care homes, they surely have sympathy for the people who live in them and would have to move if they closed. And though recession and higher unemployment levels might push more people to consider social care as an area of work, they may do so reluctantly if they are unsure about their safety and could choose to leave as soon as other opportunities arise.
The sector’s leadership has a fine line to walk in both highlighting the ongoing problems in social care and yet at the same time encouraging people to work in the sector. Similarly, leaders must somehow find a balance between expressing understandable outrage at what has happened to social care during Covid-19 and working with a government which has an 80-seat majority, nearly a full term to run and a stated intention to bring about long-awaited reform.
That balance is harder to achieve because of the fragmentation of social care. While the breadth, diversity and locally driven nature of the sector is often hailed as one of its strengths, it comes with drawbacks too. Most obviously, during Covid-19 it has meant central government was unclear about what was happening on the front line (a problem compounded by a lack of timely data). Diversity also brings with it complexity: social care can be a difficult sector to understand, and this may have contributed to (though does not excuse) the delayed central government social care response to Covid-19. This was further compounded, perhaps, by a national government tendency to centralise and circumvent local government.
More generally, the diversity of the sector creates issues around leadership. The reaction to Covid-19 demonstrated the quality, compassion and conviction of leaders in individual organisations, both locally and nationally, and there was strong focus among them on common issues such as lack of PPE and the need for testing. However, historically that unity has not been apparent when it comes to wider issues of broader social care reform. And since the sector does not speak to government with one voice, it is harder for government to get to grips with its priorities (and even harder to identify the solutions that would have wide support). Comparisons to the NHS leadership are easy but risk over-simplification – yes, the NHS has fewer national voices speaking to the government and closer alignment of asks but a centralised, command-and-control model of social care would be a huge and damaging price to pay simply for more coherent leadership.
Instead, as the sector looks to government to secure long-term reform, it needs to ask serious questions about how it best organises itself to secure commitment and action from government. Failure to learn these lessons could reduce the prospect of meaningful reform being secured and implemented well.
In summary, social care is emerging from the initial stages of Covid-19 with:
- a sector, and those working in it, struggling to come to terms with thousands of deaths
- services trying to get back to some semblance of normality – or even just stay in business
- local authorities facing increased levels of demand but uncertain finances
- (probably) wide local variations in demand, access and provision of care but no reliable data about this
- a legacy of sometimes bitter disagreement about national policy and implementation.
There are some glimmers of hope in increased recruitment into the sector, wider public recognition of social care and an apparent greater willingness by national government to get to grips with some of the fundamental issues in care. And there has been an emergent spirit of community support on which to draw. Nonetheless, reform of social care has never started from such a difficult place. That, of course, is why it is so desperately needed.
This is an excellent well evidenced review of how Covid has made visible pre existing fault lines and deficits in the social care system. The question is what will be done about them. Unless the govt is willing to address the infrastructural issues relating to the funding and delivery of social care it will go on as before to the great detriment of vulnerable adults, their families and those who work in this fragmented, atomised, and underfunded sector. The Kings Fund does a really great job of highlighting some of these uncomfortable truths in a clear and robust way.
The report is excellent but once again there is an elephant in the room when social care is discussed. It is essential to address the role of Private Equity in taking over care homes, the resulting siphoning off of huge sums often to tax havens and the consequent lowering of standards of care and conditions of employment. It has been estimated by the Centre for Health and Public Interest that at least £1.5 billion per annum is taken out of the care home sector by Private Equity in the form of rent, interest, debt repayments, management fees, massive salaries to executives, etc. The Private Equity owned care homes have had the worst result during the COVID-19 crisis in terms of deaths of residents and infection among residents and staff. The largest group, HC-One has as its Chair the former head of the CQC, and consists of a number of companies mostly registered in the Cayman Islands. In order to discuss reform of the care home sector there must be a serious analysis of the impact of ownership on the use of resources (where does the money go), the quality of care and the conditions of employment.
Once again an academic has researched the public domain and come up with--------nothing,
No solution was suggested altho to be fair,no one would have listened!!!!!!!!
Royal commissions have come and gone and governments, having taken advantage of the time wasting involved,have done nothing!
I think it was Barbara Cartland who said"When we are dead we are no longer a problem" this is as true today as then .
This admin has been gifted by the electorate with a dictatorial majority ideal for passing unpopular legislation and has done nothing to address the long term funding needs of this sector,
History will judge this as a monumental missed opportunity
there is much in there that resonates with known issues, but I wonder if you are aware of the profound implications of insurance on the sector? only once in media have I heard mention of the issues that have arisen around Insurances companies denying insurance to care homes that have a less than satisfactory grade, and significant hikes in insurance costs for those that can get them. The numbers of insurers willing to take on care homes has decreased, but the costs of getting - or not - insurance are significant and will have to be passed on, fi the care homes are to stay in business.. and that will impact the capacity and capability of the sector across its delivery. care homes might have been seen as problematic, but they are actually easier to address than the wide ranging and massively complex home supports and in reach / out reach care providers...
I hope HM Govt reads your excellent report Simon which I have shared on LinkedIn as this needs to be read. There has never been a more urgent time to sort out social care. With COVID changing peoples attitude to working away and travel needs for good - now is the time to stop HS2 and put all those billions of pounds being put aside for previous PMs vanity projects into joined up social care.
Thank you Simon for a well balanced & comprehensive reflection of issues at the heart of our social care provision. You know me well enough to know that as an ex senior NHS clinician, manager, policy lead at health authorities & wide breadth commissioner now strong advocate of social care specifically care homes, I have views on what’s important in responding to your summary.
For me it’s fundamentally about the best quality of care at the right time in the right place reflecting choice, individual wants & needs, values and beliefs that enable people to live well.
It’s disheartening that the pandemic has plunged many social care providers into further struggle & plight and that despite some recognition and perhaps a modicum on elevated status many will still see ‘ending up in a care home’ as a system failure whereas having a series of mostly avoidable, traumatic, and expensive hospital admissions as an inevitable part of the decline we witness for too many people in the final years of their lives.
Two points made in this piece I must take issue with are firstly the ‘little sympathy people have for the independent / private sector role in providing care’. The colleagues I associate with who run vibrant, progressive, positive, kind & enthusiastic care homes are totally committed to leading strong cultures of belief in fabulous person centred care with people living a fun filled, safe & balanced life. Ownership means 24/7 values, it means no off button and it also means walking the walk as much as talking the talk - we in the independent sector are truly doing this everyday and we are much maligned and seen as profiteering I assure you we are not - the risks & responsibilitIes of caring for those we look after & those we are employing is outweighed by the rewards and pride we get from leading the best care we can offer.
The second point I always react to, sadly promulgated by big corporate providers, bank managers, a number of commissioners and tragically a good many families and perhaps much of the time misguided people looking for a care home for a loved one, is big is best!
Small homely adapted older properties have done considerably better at avoiding coronavirus than the industrial scale silos of so called ‘hotel style’ palatial looking massive care institutions. My 2 very well regarded smaller homes in Devon are always full, have excellent staff doing the right things well, are viable and should be seen as worth supporting in this diverse *market of ours.
*I use the word market here but can I make a plea that we stop calling social care & care homes in particular a market. It always bothers me. More language we should resist & desist in using. It perpetuates stigma and outdated views on care
I hope these points are read well and help the much needed solution focused thinking & actions that follow
Many thanks Simon for a really well constructed piece. Speak soon I’m sure