Funding adult social care – Dimensions contributes to the Housing Communities and Local Government (HCLG) Committee

CEO Steve Scown will represent Dimensions’ views on the long term funding of adult social care at the Inquiry hearings, deferred to Monday 25th October following the tragic death of MP David Amess.

Read our written submission below (dated April 2021.)

65 organisations and individuals contributed to this consultation; find their views here.

Or watch the session on Parliament TV from 4pm

Executive Summary

Dimensions is a not for profit support provider for adults who have a learning disability and autism, supporting around 4,000 people across England and Wales.

The following evidence sets out the organisation’s experience of the pandemic and key concerns in relation to social care funding moving forward.

The submission outlines that:

–          The pandemic has created additional costs for social care providers that must be addressed as part of long term reform

–          There is considerable consensus around the aspects of social care reform that need to be addressed by government, which should provide a framework for decision-makers going forward

–          Stabilising the social care market demands proper investment, particularly to address workforce issues

–          Competing on quality and innovation is made difficult by the long-term and deepening financial pressures in social care

1. How has COVID-19 changed the landscape for long term funding reform of the adult social care sector?

Workforce pay and recognition

1.1 The pandemic has made clear the immense contribution that social care workers make to society as a whole. Social care workers have ensured that those most at risk from COVID-19 and those who are most in need of day to day support have been able to stay safe and well during the pandemic, in some cases making considerable personal sacrifices to do so. For example, one support worker employed by Dimensions lived in a mobile home, away from his family for several months, in order to continue to support people who were shielding.

 

1.2 We believe that the contribution of social care workers should initiate a new deal for the workforce, in its own right – including better pay and conditions, parity of esteem with health workers and a coherent ‘People Plan’ that supports careers in social care. We urge the government to address these issues in its plans for social care reform, with appropriate additional funding – failure to do so will show a complete disregard for the dedication and determination of social care workers, who have played a central role during that pandemic and who are yet to be properly recognised for this.

 

1.3 Beyond this, the experience of the pandemic has shown that longstanding issues in social care relating to workforce pay and recognition need to be resolved in order to futureproof the sector from future pandemics. For example, the reality of low pay and relief contracts for many social care workers means that people will often work across a number of care settings – this presented particular difficulties in terms of reducing the risk of transmission between care settings during the pandemic.

 

1.4 Additionally, evidence within the sector underlined that many did not feel they were able to self-isolate during the pandemic, for fear of loss of income, an issue that arises from enduring low pay and weak protections around sick pay.[1] The pandemic has underlined the fact that long-term reform of adult social care must address workforce issues, demanding investment from central government to ensure that local authority commissioned contracts can meet the costs of paying the workforce appropriately and the costs of ensuring adequate conditions of employment.

 

1.5 It must be acknowledged that many providers, including Dimensions, sought to mitigate these risks as far as possible. For example, Dimensions took the decision at the start of the pandemic to introduce sick pay from the first day of sick leave for all colleagues, in order to remove any disincentive to attend work having contracted the virus. Prior to the pandemic, Dimensions’ policy was that the first 3 days of sick leave per annum were unpaid. We also paid people who were forced to self-isolate as a result of a positive test, thus reducing the need to attend work in order to not lose pay. The additional costs for measures such as these have not been fully met by the government. We believe firmly that decisions such as these did right by our colleagues and the people we support, but we underline that central government should have done more to ensure for the sector as a whole.

 

1.6 At their core, workforce issues derive from decision making by central government and the funding that is provided to local authorities to meet their statutory duties. Non-profitmaking organisations are unable to offer beyond the funding packages made available through local authority commissioning and, whilst many providers and indeed commissioners may wish to see a better deal for the social care workforce, this is made incredibly difficult by the current pressure on funding in local government.

Additional costs arising from COVID-19

1.7 The pandemic has caused many providers to incur significant additional costs, some of which has not been met through the funding made available by central government. We welcome the extension of financial support to meet the ongoing costs of infection control up to March 2022. It is as yet unclear how long stringent infection control measures will be necessary within adult social care, however we foresee an enduring requirement for them. Any future funding settlement must consider these new additional costs and the fact that there may be an ongoing need for the use of PPE and regular testing systems.

1.8 We urge the government to consider the specific circumstances of adult social care within its review of social distancing rules and infection control measures (including mask wearing) and emphasise that this consideration must extend beyond the needs of registered care homes and services for older people, to include supported living, day services and other forms of provision for people who have a learning disability and autism – many of whom are at increased risk from COVID-19 due to systemic barriers in healthcare and higher prevalence of underlying health conditions. Ongoing costs must be built into local authority commissioning arrangements, to ensure that the new financial burden of infection control measures does not land directly on providers.

Lack of preventative care and rising need

1.9 The unprecedented pressures placed on health and social care services over the pandemic are likely to have a long term impact. As an example, we are aware that some people we support who have complex health needs have not been able to access timely care from community health teams, such as input from Occupational Therapists around postural care. These services often prevent people from losing independence and requiring additional support from health and care services and we believe the lack of access over the past year may mean that a higher number of people have increased needs.

1.10 This is likely to have an impact for adult social care funding, as local authorities will see a rise in need amongst those who are already in receipt of social care, as well as increased demand from those who currently don’t receive any support. Any future funding solution should address current and rising unmet need, as well as ensure that sufficient early intervention and preventative services are in place to enable people to live with greater independence for longer. Whilst this issue pre-dates COVID-19, it is likely to have been exacerbated by the disruption to health and social care provision over the past year.

 

2. How should additional funds for the adult social care sector be raised?

2.1 Dimensions vision for social care is one that is shared by many who receive social care and their loved ones and that has been developed by the Social Care Future movement.[2] We believe that we all want to live in a place we call home with the people and things that we love, in communities where we look out for one another, doing the things that matter to us. Social care is a critical part of ensuring this for many people who have support needs.

2.2 There are many aspects of social care reform on which those receiving social care and organisations providing social care can agree – including the need to join up services around the person; provide support in a way that promotes wellbeing; ensure that workforce pay and conditions incentivise the right people to work in social care; create an equitable system whereby the costs of social care are not overly burdensome on individuals who require it; and the need to enshrine principles of choice, control, independence and dignity into the models of support that are available across social care provision.

2.3 We believe that these agreed aspects provide a framework around which reform can be built and that it is now up to our political representatives to determine the most equitable and effective way of funding adult social care so as to deliver that around which a consensus has been built.

2.4 We emphasise that there is a risk, currently, that the issue of long term funding and social care reform will be viewed too narrowly, addressing only whether people need to sell their home in later life if they come to need social care. This overlooks the needs of many working age disabled adults and those who have lifelong health conditions or disabilities.

2.5 We also emphasise that the issues extend beyond the provision of free personal care. Whilst we do not believe that free personal care would be, necessarily, a negative step in the reform agenda, it must be acknowledged that social care provision extends far beyond the provision of personal care and that a long term funding settlement must ensure that people are able to lead the lives they choose to lead and that they are able to maintain wellbeing.

2.6 We believe that social care offers opportunities for economic growth and should thus be seen as an opportunity for investment. Though the estimated funding gap is significant and may initially seem an insurmountable challenge for the Treasury, there is much to indicate that social care is a sector for investment and an area in which public money can be used more effectively than if spent elsewhere. This is, not least, because social care often offers preventative services that reduce the need for later interventions at more significant cost:

• Community support services can reduce the likelihood of people who have a learning disability and autism who display distressed behaviour ending up in costly mental health detention or in the criminal justice system.
• Social care can provide the support working age adults who have disabilities need to gain employment – for example, support to travel to and from employment or support with day to day living that makes paid employment more manageable.
• Social care can assist people who have a learning disability and autism to maintain health and wellbeing and reduce the need for secondary healthcare services.[3]

2.7 Additionally, at a local level, the money invested in social care services as frontline pay often goes directly into local economies, with many who work in the sector living locally to where they support people through commissioned services. As we come out of the pandemic and begin to address the significant economic toll of lockdown, investing in social care may provide a valuable option for recovery in areas where unemployment is high.

3. How can the adult social care market be stabilised?

3.1 Instability within the social care market arises primarily from the ongoing funding pressures in adult social care. Indeed, these pressures have meant that some providers have been unable to weather the storm of the pandemic.

3.2 Hft’s Sector Pulse Check 2020 report has found that 62% of learning disability support providers had to close down some part of the organisation or hand back marginal contracts and services to the local authority over the past year due to cost pressures.[4] This underlines the impact that instability in the social care market has on the lives of people who receive services – where they may find the delivery of their care handed over to a different provider, whom they do not know or prefer. The report also found that 11% of providers have offered care to fewer individuals over the past year, underlining that instability will leave reduced choice within the market for those who are in need of social care.

3.3 We underline that stability in the market demands proper investment in social care to address issues in workforce pay, enable providers to meet unexpected costs such as those that have arisen through the pandemic and to cover the growing statutory costs that providers must meet, including rising National Living Wage rates and pension contributions.

3.4 We note the proposed power for the Secretary of State to intervene through direct payments to social care providers, which is set out in the government’s white paper on integration, Working Together to Improve Health and Social Care for All. We are concerned that this power may provide a means by which short term issues for individual providers are resolved, offering only temporary solutions in the market and at the same permitting the issue of long term stability to remain unaddressed. We stress that such a situation would fail to resolve long standing issues in social care and might, over time, lead to the social care market becoming less stable.

4. How can the adult social care market be incentivised to compete on quality and/or innovation?

4.1 It is increasingly difficult for providers to compete on quality and innovation against a backdrop of severe underfunding. Well intentioned providers are prevented from investing fully in their workforce, which is a critical aspect of ensuring quality service provision, due to the limits on local authority spending that are currently in place.

4.2 A strong example of the disincentive that exists in policy at the moment is the guidance on sleep-in payments, recently decided in the UK Supreme Court.[5] In response to the litigation brought over sleep-in pay many providers, including Dimensions, introduced wage top ups to ensure that no one carrying out a sleep-in shift is paid below minimum wage for the total time they work in each pay period. We believe this is the right approach to have taken, however it has significantly eroded pay differentials within support teams, thus undermining proper recognition for members of the workforce and creating disincentives to advance within a career in social care. The Supreme Court’s decision casts doubt on whether local authorities will accommodate ongoing wage top-ups in future contracts. Policies such as these underline the way in which the lack of investment in adult social care and the tendency to push issues of reform down the road have created an uphill struggle for providers wanting to create rewarding working environments.

4.3 Sleep-in policy is just one example within the overall context of underfunding in adult social care, which presents issues for recruitment and retention.[6] Whilst there are many highly skilled, compassionate people working in social care, it is increasingly difficult to recruit people with the right skills when the pay offered is lower than that offered in other industries, such as hospitality or retail. CQC has assessed staff turnover for social care workers to be at around 40%, significantly higher than roles in healthcare (for example, turnover rates for nurses in NHS acute trusts is 11.9%).[7] Problems such as these create unnecessary costs and undermine efforts to build stable and reliable support teams, who can be properly trained and developed in their roles and who operate under consistent leadership – all of which are crucial elements of ensuring quality.

4.4 Additionally, whilst providers are ‘firefighting’ such issues, innovation can be hard to implement and the same issues that undermine quality also serve to make a difficult environment in which to try and test innovations. Indeed, in the current climate, providers can be forced into making difficult choices about whether funding should be invested into frontline pay or other innovations that might improve the support that people receive. Were workforce issues resolved, it would free up resources that could be used to innovate and improve support offers, including investment in technology.

4.5 We emphasise that many of the issues in quality that arise in social care relate back to commissioning and funding, which can impede providers from delivering services in the way that works best for the people they support. As an example, one of the most significant issues for Dimensions in terms of ensuring quality support and a good life for each person we support arises when people end up living in a setting alongside someone who they do not get on with. Often this situation arises because there is not an alternative place in which they can be supported and commissioners are unable to move someone to a place that would be more suitable within the person’s allocated funding. Resolving the incompatibility issue is often outside of the control of Dimensions as the provider. It is unlikely that people in this situation would feel they receive a service that truly meets their needs, even if they feel that their support team are good and that Dimensions is a quality provider.

4.6 Despite these issues, there are innovations taking place within the sector, both technological and through new models of support. Dimensions has introduced the Activate model[8], an approach to person centred support that focusses on the outcomes people achieve through having the right support. Such an approach ensures that the support someone receives is built around what they want to get out of life and what they feel is needed in order to achieve this. Such approaches do not always align with the approach taken in commissioning and can therefore mean that innovations that create higher quality provision for an individual are not prioritised over innovations that might reduce the costs of delivering support to that individual. It should be acknowledged that, when done collaboratively and effectively, quality support often supports people to gain independence and reduce their overall need for support in a way that works for them and we believe this should be a central consideration for commissioning decisions going forward.

4.7 In terms of incentivising the market to compete in relation to quality and innovation, we make the following recommendations:

• Prioritising outcomes based commissioning that considers how people will be supported to achieve what they want to in life and how support will empower people to live with greater independence – for example, through the maintenance of their health and wellbeing; through accessing paid employment; or through developing new skills.
• Prioritising co-production, where people and their loved ones are meaningfully and equally involved in shaping the support they receive and determining how best to ensure they have the right support to get what they want out of life.
• Prioritising collaboration and integration, so that providers who work effectively with other services, particularly healthcare, are recognised and have opportunities to support people in a holistic way that helps people to gain and maintain greater independence.

References

[1] https://www.unison.org.uk/news/press-release/2020/06/care-worker-pay-deductions-must-tackled-stop-hardship-control-virus-spread/

[2] https://socialcarefuture.blog

[3] Presently, health inequalities and barriers in services mean that people who have a learning disability are 5 times more likely to end up in hospital for health problems that would normally be treated through primary care, Being Disabled in Britain, Equality and Human Rights Commission, 2017

[4] https://www.hft.org.uk/wp-content/uploads/2021/03/Hft-Sector-Pulse-Check-2021.pdf

[5] https://www.supremecourt.uk/cases/uksc-2018-0160.html

[6] It should be noted that issues in relation to recruitment and retention have lessened due to the economic impact of the pandemic and rising unemployment, however we do not believe these changes will be sustainable and there is an ongoing need to resolve the root causes of issues in recruitment and retention that pre-date the pandemic.

[7] The State of Health and Social Care in England 2018/2019, CQC

[8] https://dimensions-uk.org/initiative/activate