NCF Policy Agenda
Long-term ambition not a quick fix
Social care matters. It matters to the millions of people who want to use and shape it; to the 1.52 million strong workforce; to over 10 million unpaid carers; and to the 18,200 organisations providing it. 1
The government must take this opportunity to be ‘ambitious for social care’, a once in a generation chance to reform and invest in social care so it can continue to make a transformational difference to the lives of the millions who use it now and the millions more who will need it in the future, their families and carers and those who work in it. Social care helps millions of people to live their best lives – with the right focus, support and investment, this government can be the one that delivers for social care.
This paper sets out very clearly the reform ambitions from the National Care Forum. We are the voice of the not-for-profit care and support sector. Our members:
- Provide care and support to over 170,000 people
- Operate over 9200 services
- Provide more than 45,000 care home places
- Employ over 93,000 staff and work with 13,500 volunteers
The National Care Forum works closely with a diverse membership of not-for-profit care organisations who are embedded in their local communities. Our members provide care and support to a wide community of people – including older people, people with learning disabilities, people with other types of disabilities, people with mental health needs – who are supported in their own homes, in care settings and in the community. Building on this unique perspective and in-depth experiences, we have developed the following set of principles to underpin the reform of social care.
Promote people’s independence, wellbeing and dignity
Ensure choice of good quality person-centred care and support which responds to the wishes and needs of all the people who make use of it
Be co-produced with people who use care and support now and people who will use it in the future
Focus on prevention, offering people the care and support they need it, when they need it, where they need
Provide fairness for people who need to use care and support now and in the future
Deliver long-awaited reward and recognition for staff who work in social care
Maximise the social and economic value of care and support
Enshrine a rights-based approach for people receiving care and support and people working in social care
These principles run through each of our specific reform ambitions of the government.
Our Reform Ambitions
We need fundamental reform of social care and not just a recovery from the experiences of the last year. The government must take the opportunity to use its reform plans to put social care at the heart of its policy planning, to think Social Care First and design a social care system that is person-centred, fair and fit for the future.
Why should the Government ‘Think Social Care First’?: With a sounder understanding of what social care is and does and how important it is to people in their everyday lives, and an honest discussion about what people want, there is a real, once in a generation opportunity, to create a reform approach that offers a much more personalised, person-centred care and support model, improves prevention and early intervention and which saves money and misery and does not see social care simply as the handmaiden of the NHS. The breadth and impact of what social care does, for the very wide range of people whom it supports, must be front and centre of reform plans
What must the Government do to ‘Think Social Care First’?: The government must take the opportunity to use its reform plans to put social care at the heart of its policy planning, to think Social Care First and design a social care system that is person-centred, fair and fit for the future. The focus must be on the people supported by care and support, and those who will need it in the future, and the importance of helping them to live their best lives every day.
COVID-19 experience and wider learning: The experience of our members over the past year illustrates the very real consequences of not thinking ‘Social Care First’. The focus on protecting the NHS during the first wave led to delayed access to COVID-19 testing, PPE and clinical support across the care sector.
NCF campaigned systematically to improve access to COVID-19 testing, one of the essential frontline defences against the virus; symptomatic testing was first promised in April 2020 in the Social Care Action Plan but it limited this to those with a narrow list of symptoms, as our LESS COVID research highlighted 2. In reality, testing remained hugely problematic for care homes until reliable regular asymptomatic testing was finally established September 2020 3. It has taken until February 2021 for all social care settings to get access to regular asymptomatic testing.
Our members also reported that many community health teams and clinicians were asked to withdraw support to social care during the first wave to focus on getting people out of hospital to free up beds for potential COVID-19 patients. The focus on urgent hospital discharge, led to huge difficulty in getting access to wider clinical support and admission to hospital for essential care and treatment when needed as well as significant concerns about blanket DNACPR orders, particularly in relation to people with learning disabilities
Access to PPE was also problematic during the first wave. Some of our members were told by their suppliers that the NHS supply chain had priority access to their stocks over social care providers and in some cases, our members had their orders cancelled in favour of the NHS. Where supplies were found with wholesalers some of our members reported price hikes of over 1000%. The National Audit Office report would appear to back up our members’ experiences. Between March and July 2020, adult social care received 10% of its estimated need compared with 80% for the NHS from central government 4. It took over six months to establish a free and reliable supply of PPE to the sector, when finally in September 2020, free PPE via the portal was announced until March 2021 (subsequently extended to March 2022). Finally, a lack of understanding of social care resulted in numerous and frequent changes to the PPE guidance, adding to the daily burden of trying to manage COVID-19.
COVID-19 has significantly increased the immediate financial pressures on the adult social care sector. This has highlighted the importance of finding a long-term funding solution to stabilise, sustain and grow the choice of high quality, resilient and accessible care and support services, for all of those people in need of help now and in the future. Investment in Adult Social Care will improve the choice, accessibility, quality and sustainability of services for those supported by it as well as bringing wider economic benefits to the country. It will also enable people to remain in or enter the job market, especially those who would otherwise be unpaid carers and some of those receiving care.
Why should the Government invest in social care?: Investment in Adult Social Care will improve the choice, accessibility, quality and sustainability of services for those supported by it as well as bringing wider economic benefit to the country.
In 2019/2020, Skills For Care found that the net economic benefit of the care sector in England alone was £41.2bn. 5 Social care is very much a local enterprise, providing local employment in local areas, bringing the economic benefit of local wages spent in local shops and businesses, supporting local supply chains and paying local taxes. It also enables people to remain in or enter employment, especially those who would otherwise be unpaid carers and some of those receiving care. It is time for government policy to recognise social care as a vital contributor to the economy
What must the Government do? Seize the opportunity to end the short-termism over investment, stop lurching from one announcement of emergency funding to another, and devise a streamlined long-term social care investment plan which maximises the investment potential, ensures funding reaches the frontline and ensures greater transparency about investment, wider economic benefits and returns to society. Alongside revenue investment, the government must explicitly consider how to support the sector with longer-term capital investment; COVID-19 has highlighted the importance of future-proofing residential settings with good building design, good ventilation, the importance of indoor, flexible space and the essential need for access to outside space.
COVID-19 experience and wider learnings: work with our members, who are all not-for-profit providers of care and support, has shown that during 2020 they have experienced a damaging combination of large rises in their costs and significantly reduced income, due to a combination of lower occupancy levels for residential settings, increases in equipment costs (which have risen by 15%), significant increases in supply costs (which have risen by 55%) and significant increases in insurance costs with reduced cover. We also looked at the impact of increases in costs by calculating an average operating cost per care home place, and while this is, of course, highly variable between organisations, we found it rose on average by £5k per place. Financial confidence is very low, 75% said their revenue was down, and 83% said their costs were up creating greater fragility to an already stretched and underfunded sector.
Short-term emergency injections of cash into the system through the various iterations of the Infection Control Fund as well as the Rapid Testing Fund and the Workforce Capacity Fund while a welcome sticking plaster, do not offer a sustainable solution to the funding pressures; the most recent announcement of £341m was welcome but it was impossible to not note the disparity in treatment of social care and the NHS. Out of the £7bn announced in March 2021 by the Secretary of State, less than a twentieth of it was ring-fenced for social care 6.
The current mechanisms available to the government to invest in social care have highlighted challenges in getting money to the frontline of care, proving to be a cumbersome and inefficient set of processes.
The Health & Social Care Select Committee found in 2020 that the social care system immediately needs additional funding of at least £7bn per year in England to simply stand still and deal with demographic changes, the fallout of the pandemic, uplift staff pay with the National Minimum wage and to protect those facing catastrophic social care costs. 7 Longer-term, significantly more per year is required to create a social care system that is sustainable, accessible to everyone that needs it and provides the best care possible
COVID-19 has highlighted just how important it is to invest in the social care workforce to create a professionally skilled, recognised workforce, that is properly valued, better paid and has more training and development opportunities
Why should the Government invest in our care workforce?: Great care needs great people to provide it, yet there has been no dedicated national social care workforce strategy for social care since 2009. Investing in social care also means investing in the workforce. This will bring a range of strong economic and quality benefits as well as enabling social care employers to pay social care workers better, at levels which properly reflect their skills, competencies and expertise and at levels which improve staff retention, reduce staff turnover and support recruitment.
What must the Government do? The barrier to improved pay and wider terms and conditions for the workforce has been the lack of investment and the lack of strategic policy steer from the government. This is not something individual organisations can do on their own. The government must develop a fully funded People Plan for Social Care that provides clear career progression, better recognition and valuing of staff, investment in staff training and support, and introduces professionalisation and registration where this is appropriate. This will improve our ability to recruit and retain high quality, skilled social care staff with the right values and our ability to grow innovative models of support, as well as to develop and recruit a workforce that reflects and understand the needs of communities being served.
The Social Care Taskforce Workforce Report in 2020 8 recommended that the ‘Government should instigate a review involving employers, commissioners, and employee representatives with a view to implementing a new career-based pay and reward structure, in-year, for social care which will be: (a) comparable with the NHS and equivalent sectors; (b) fully-funded by Central Government; and (c) mandatory on employers and commissioners of services.’ This remains a very clear NCF ask.
COVID-19 experience and wider learnings: throughout the pandemic, our members have told us about the commitment, dedication, bravery and care of their staff. They have been the stalwarts of the Covid-19 front line. 24 hours a day, seven days a week, continuing to provide care under the most challenging of circumstances. They have done this with compassion, providing a lifeline for the most vulnerable across all our communities.
Public perception polling that the NCF carried out in the summer of 2020 found that three quarters (74%) of adults in England believe care home staff do a brilliant job. It also shows an overwhelming belief that care workers are undervalued (81%) and 80% of adults in England believe that care workers should be paid better.
Our Caring in COVID ebook 9 is an important part of the legacy of the COVID-19 pandemic and describes the role played by NCF members and their amazing workforce. We reached out to NCF members so that we could bring together these uplifting stories of community, the frontline, leadership, connection and fun in one place. The ebook reflects a selection of the wonderful stories we received from the start of the pandemic up to mid-October 2020.
Our LESS COVID research 10 highlighted systemic issues associated with ‘a lack of wider recognition and value of the contribution of the care home sector and (importantly) its staff.’
The lack of a coherent Social Care People Plan and care worker registration scheme really hampered the Government’s ability to respond to COVID-19; the absence of a systematic way to identify care workers has made it very difficult to identify care staff, both as essential keyworkers and support for them in the first wave (access to supermarkets, essential travel, access to schooling), and as the JCVI priority group one for urgent COVID-19 vaccination. And, as the understanding of the transmission of COVID-19 grew, the focus moved from care staff as a dedicated, compassionate, caring workforce to one that saw them as inadvertent vectors of infection, despite the heroic efforts across the sector with PPE, testing, IPC and now vaccination.
Skills for Care data highlights that 1.52m people work in social care (compared to 1.3m in the NHS)11, with 113,000 vacancies (vacancy rate of 7.3%) and an average turnover rate of 30.4%. The NCF Personnel Survey 2020 (data to end of March 2020) showed that our members saw 22% turnover with a vacancy rate of 8%.
The NCF represents the not-for-profit care and support sector, which offers greater transparency in terms of governance, finances and accountability than the wider sector. We strongly advocate for more focus in the Government’s reform plans on recognising the benefits and social and economic value of the not-for-profit sector, which will help to give politicians and the public reassurance in their investment in social care.
Why should the Government support and promote not-for-profit care?: Social care delivers public good, and much of it is funded by the public purse. Primary legislation such as the Social Value Act also exemplifies the importance of using public money to invest in services that support wider community ambitions. Not-for-profit care provision ensures that all of the funding from either government or citizens is directed towards the delivery of care now and in the future, ensuring that the money remains in the sector and is reinvested to improve the quality of care.
The not-for-profit organisations we represent place a strong emphasis on the long-term sustainability of their care and support services in the local communities they serve, often having deep roots due to their origins and history in local areas, alongside their focus on person-centred care.
Many not-for-profit organisations providing care and support are charities or social housing providers, meaning they are not just accountable to the CQC but also the Charity Commission and the Social Housing Regulator. As a result, the organisations we represent, by their very nature, have a very strong culture of accountability, governance, diversity and person-centeredness.
What must the Government do?: Recognise the enormous potential for not-for-profit care in delivering greater social and economic returns to the communities that they serve and look to incentivise this model of provision in any reform plans. We strongly advocate for more focus in the Government’s reform plans on recognising the benefits and social and economic value of the not-for-profit sector, which will help to give politicians and the public reassurance in their investment in social care. This will be especially important if the Government is considering a social care insurance model to pay for future care needs.
COVID-19 experience and wider learning: Our public polling research during the summer of 2020 showed that the public has a clear preference for not-for-profit care provision. The public expressed greater confidence in relation to the quality of care and the trust in the organisation delivering it.
The values, quality-focus and person-centredness found amongst our not-for-profit members have also shone through, particularly with regards to visiting arrangements to care homes and other residential settings. NCF and many of its members have been at the forefront of advocating a less prescriptive approach to visiting 12 in order to protect the rights and wellbeing of residents of care homes, extra care and supported living settings.
The not-for-profit part of the sector has great potential and should be encouraged to grow to take a bigger share of the market.
We are calling for a Fair Price for all types of care, to ensure that it meets the true cost of good quality, sustainable care. This means that a Fair Price for care needs to be met by the state when commissioning care on behalf of people and this, in turn, will enable providers to rebalance the prices paid by individuals who fund their own care and create a sustainable care offer for the future.
Why should the Government create a fair price for all care: the current system puts a huge burden on those who need, and are able to pay, for their own care and support under the current means-testing arrangements (usually older people). It is perceived to be fundamentally unfair, creates huge uncertainty and anxiety about the future care costs people may incur and creates a complex system around costs of care at precisely the time when care is needed urgently, often as a result of a crisis. Where the state is funding care and support, many of the current commissioning approaches by some local authorities do not reflect the true costs of providing high quality, accessible, sustainable care.
Many others have rehearsed the different options for how to fund the additional long-term investment in social care, with their pros and cons. At the NCF, we believe it is important that the option chosen assures key elements of intergenerational fairness – the way we choose to invest in and pay for care and support (both now and in the future) must balance the burdens and benefits across the generations.
What must the Government do? Establish a framework for a fair price for care which ensures good quality, sustainable care wherever you live and removes the catastrophic costs providers, individuals and families are being expected to pay to subsidise the current system. It must provide fairness and confidence for people who need care now and in the future and ensure that good quality, sustainable care is maintained and planned as well as ensuring that staff are paid in line with the skills and expertise they bring.
COVID-19 experience and wider learning: Our membership has been struggling with the extremely low fee rates being offered by commissioners long before the pandemic, but COVID-19 has exacerbated this. In February 2021, our members reported that local authorities did not seem to be able to offer increases in fee rates for 2021/22 that would go anyway near to compensate the real costs providers were facing. Of the 39% that had been offered an increase in fee rate, just under half of them had had an offer of an increase of less than 2.2% – many were well below the increase in the national living wage in April 2021. This has not left room for other increases in costs for this financial year. 13
Numerous reports have highlighted the fundamental unfairness of the current situation faced by many older people who need care and support who face potentially catastrophic costs to meet their needs if they are not eligible for support from the Local Authority (LA) or NHS. It is also clear that LAs are facing very real challenges in terms of the rapidly rising costs of care and support for working-age people and for children and young people, putting further pressure on funding available and eligibility criteria.
These financial pressures can result in a wide range of commissioning approaches by local authorities which result in unsustainably low levels of funding for care. The NAO report found that:
‘For 2019-20 the Department assessed that the majority of local authorities paid below the sustainable rate for care home placements for adults aged 65 and over and below the sustainable rate for home care. The Department does not challenge local authorities who pay low rates’ 14.
Many older people who have to cover the costs of their own care are also being hit by a ‘cross subsidy’ effect as the state pays below the true cost of good quality care for those who cannot afford to, which results in an increase in costs for those who can. Analysis from the National Audit Office highlights that ‘this cross subsidy can be significant: on average, a self-funder’s place costs around 40 per cent more than one paid for by the local authority.’ 15
Social care reform plans must be underpinned by an understanding of the need for effective integration of care, health and housing. Reform must recognise the relationship between social care and housing, where housing is a key element in sustaining the independence, choice and dignity amongst people of working age and older adults, supported by access to the social care that will help them to live their best lives. These must be future-proofed to reflect the UK’s ageing population and the increasing complexity of needs in people of working age. Access to good healthcare, social care and mental health services will be fundamentally undermined if quality housing is not available.
Why should the government recognise the importance of housing in social care? The Government’s reform plans must recognise the important role of housing in social care as it is a critical element in choice, independence and dignity. While the perception is that many people want to remain in their own home for as long as possible, this may not possible if their housing is not suitable and effective home care is hard to come by.
We know that retirement communities and extra care settings have enormous potential to enhance the lives of older people in terms of their physical and mental health, helping them to maintain their independence for longer and reduce the strain on health and care services. Care homes provide an essential home for those who are more frail, with more complex combinations of needs, where independent living is no longer an option.
It is also clear that options for those of working age with complex needs are often limited, resulting in people having to travel far from family and friends to access the care that they need with all the challenges this presents.
What must the Government do? There must be a dramatic increase in the supply of housing that facilitates a wider range of care and support, so every area in England has access to the full spectrum of care options. The Government must join up the national and local approaches to the provision of housing to create an effective system for delivering a coherent housing policy with better options for maintaining independent living.
COVID-19 experience and wider learning: The Commission on the Role of Housing in the Future of Care and Support produced some helpful findings 16. We need better housing choices for people to help them age well and to respond to the lifetime needs of those who live their whole lives with complex needs; the quality and quantity of housing with a range of care and support needs to be improved.
The planning system needs reform, both for housing for older people, such as retirement communities or extra care housing, and for housing for younger adults who have long term and often complex needs. We need a joined-up approach to commissioning housing choices involving care homes, housing, housing developers and health and social care – working in close and equal partnership, connecting social care to wider housing and infrastructure.
Technology can hugely improve the lives of people living in housing with care and support. COVID-19 has accelerated the take-up of new technologies in care settings and demonstrated how liberating technology can be. Developing new forms of housing with care and support that feature useful technology has the potential to enhance care experiences and outcomes.
Reform plans must include the future-proofing of social care with specific measures to encourage innovation, digital transformation & new models of care. We need sustainable transformation and infrastructure funding beyond pockets of brilliance to support social care to meet the needs of the care customer of the future. This should be treated as an integral part of public infrastructure.
Why should the Government future-proof social care? To equip us for the future of social care, the government must support research and debate with the future customers and the families and loved ones of those who will need and want care and support. It must take the opportunity to explore and co-produce new models of care and innovations in care which will better meet people’s needs and choices. The demographics of our future customers is changing quite rapidly and we must prepare to meet their needs, be that increasingly diverse communities, more people who are LGBTQ+ or those ageing without children. Commissioning and procurement practices will require a significant culture change to encourage and fund innovation and manage the risk and opportunities ahead. The approach from the regulator through its new strategy and regulatory framework, needs to reward innovation, and in particular, digital innovation.
Technology is also a key element in the reform of social care. If there is to be a successful and long-lasting reform to the social care system, the government needs to seize the opportunity to use innovation, digital technology and data, to generate the insights necessary for a joined-up approach which enhances the quality of care, independence and the prevention focus as well as proving a view on the effectiveness and impact of the sector.
What must the Government do to future proof social care? The government must capitalise on the potential of digital technology in social care and create an infrastructure fund, to enable the sector to speed up its adoption of proven technologies, which can enhance quality of care and outcomes for people, such as artificial intelligence, assistive technology, predictive analytics and apps. This must be underpinned by the implementation of high-speed broadband, WiFi and 5G needed to make a digitally-enabled and data-driven social care a reality.
The new Data Strategy for Health and Care must look beyond centralised data collection for DHSC. Care must also be taken to recognise the different ‘data philosophies’ in social care and the NHS. The sorts of data desired by NHS commissioners and clinicians will be very different to that desired by LA commissioners and social care providers – we need to ensure that the correct data is captured. It must be co-produced with the sector and it must balance data burden with data benefit and clarity on data ownership and access. Data is not free, so the strategy must ensure that it meets the costs of increased data reporting requirements faced by the providers of that data.
Work is already underway to create a minimum data set for care homes in the NIHR funded DACHA study 17. The Government must consider this important research and use it to inform the Data Strategy.
COVID experience & wider learning: The COVID-19 pandemic has seen a step change in the use of digital technology; this has included the wider adoption of technology for communication between people using care services and their loved ones, such as the increased use of IPads, tablets and hand held devices as well as using these for much greater digital communication with health professionals and GPs.
It has also seen a rapid increase in the use of NHSmail and an increase in the take up of the Data Security and protection toolkit to ensure that care providers information governance and cyber security is equipped for the digital age.
COVID-19 has also accelerated the recognition by care providers of the importance of digital maturity in terms of systems that support the quality of care provided, such as electronic care planning and electronic medication systems. The NCF’s Hubble Project 18 is a good illustration of what providers can achieve with digital technology. The project tells the end-to-end journey of three of our members’ as they procure, implement and measure the impact of new technologies.
The Capacity Tracker take up during COVID-19 has been remarkable, even when linked to funding. However, it represents an amalgamation of emergency pandemic data collection, built on short-term requests for particular pieces of data to answer urgent pandemic related policy questions. It is not the basis from which to build a meaningful data strategy for the care sector. It is also incredibly burdensome for care providers to complete. Data transparency is fundamental as for too much of the pandemic, social care has been specifically excluded from the insights data brings which could have helped with our response.
Local integrated health and care systems must ensure meaningful partnership between health and care if they are to meet the care and support needs of their local populations. The new Integrated Care Systems (ICS) and Integrated Care Partnerships will be an important part of the landscape for social care in the years ahead. It is essential that the legislation and guidance for ICSs puts the voice of those that use care and those that provide it at the top table of decision making and fund this as necessary. Simply involving Local Authority and NHS commissioners is not enough, as they cannot, alone, be the voice of social care.
Why should the government do this?: By guaranteeing that the voice of the people that use social care and those that provide it are rooted in the structures of the new ICSs, the government will enable a consistency of approach across the country, that there is parity in the relationship and policy development of health and social care, and that ultimately better outcomes are produced for those who need care and support.
Total localism without some mandated national structure seems likely to bring a postcode lottery of quality and effectiveness and social care reform must not be constrained by governance and decision-making structures that reinforce an NHS-centric approach.
What should the Government do? Introduce a standard national framework model for the membership of ICSs that creates a defined role to ensure the voice of people using care and a defined and funded role for local care associations/ care provider forums, with a clear role in decision-making, governance and accountability.
COVID-19 experience and wider learning: The experience of our membership during the pandemic reinforces why it is important to have the voice of the individual receiving care and the social care provider at the centre of any policymaking, service design or integration.
They also highlighted how important relationships across the local health and care system are to ensuring effective joined-up working in the interests of people receiving care and support. The experience of the Enhanced Health in Care Home programme has highlighted some very positive examples of how multidisciplinary teams of care and health staff can work together to support the joined up care and treatment of people living in care homes. However, this has not been consistent and the ICSs represent an opportunity to strengthen local systems to make this a uniform experience across all places.
Future integration must ensure more consistency of approach that focuses on the needs of those receiving care and support, thinking both about those who will need care and support across their whole lives, as they move from childhood to adulthood as well as those whose needs evolve due to age or circumstance.
1 https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-2020.pdf & https://www.carersuk.org/news-and-campaigns/news/carers-week-4-5-million-become-unpaid-carers-in-a-matter-of-weeks
3 Regular testing began in care homes for older adults in July 2020 but issues with Randox testing kits caused significant delays until September 2020
7 As pointed out by H&SC – Social Care: Funding and Workforce report 2020
17 Developing research resources and minimum data set for Care Homes’ Adoption and use (DACHA). It is a collaboration between the Universities of Hertfordshire, Cambridge, East Anglia, Newcastle, Leeds, Nottingham, Kent, Exeter, Glasgow; The Health Foundation; and the National Care Forum; led by Professor Claire Goodman, University of Hertfordshire (Chief Investigator). https://arc-eoe.nihr.ac.uk/research-implementation/research-themes/ageing-and-multi-morbidity/amm01-developing-resources-and