Debate on the state of social care in England, and the case for a comprehensive social care strategy and further support for unpaid carers, House of Lords, 10 October 2024

• The LGA is the National Voice of Local Government. We’re on the side of councils: promoting their work, supporting them to improve and helping them make a difference to people, places and the planet.
• We aim to be the best membership organisation we can be. As the national membership body for local authorities, we provide the bridge between central and local government and we help councils deliver the best services to their local communities.

• At its best, adult social care helps ensure that everyone can pursue the things that matter most to them, irrespective of their age or conditions. Yet this core purpose of adult social care, and its intrinsic value to us all, is not well enough understood. Changing this could help unlock more public support, making it possible to spread the very best practice that exists across the country.
• There must be joint work with an incoming government to reform – in coproduction with people drawing on care and support – the approach to adult social care, and better joint working between the NHS and local government to support people. In particular, a focus on prevention and recovery services is needed. Investment in primary and community services and intermediate care that is multidisciplinary and can resolve crises in health and care would mean avoiding hospital admission and helping people convalesce. More therapeutic-led reablement – intensive short-term interventions with follow-up support – will support recovery after time spent in hospital.
• The LGA’s White Paper revealed that councils in England now face a funding gap of £6.2 billion over the next two years. Adult social care must be funded adequately, sustainably and with trust in councils as democratically accountable bodies. The exact funding requirement should be identified through a collaborative process, but we broadly support the Health Foundation’s analysis of the uplifts that would be required to tackle some of the most pressing issues facing people and the sector, such as access/unmet need, meeting future demand, and covering the full cost of care.
• There must be support for the voluntary sector, which can mobilise quickly and provide access to an additional workforce. Services such as ‘sitting services’ (which provides reassurance for people who may not need care but are concerned at being alone after discharge), unpaid carer support, handyperson services, and home from hospital services can all play a key role in meeting low-level needs after discharge, as well contributing to preventing possible readmission.
• Support for and recognition of unpaid carers – who are the backbone of care – is crucial. Too many of these people are suffering ‘burnout’ and the labour market is losing too many people, especially those in their 50s, who are having to give up work to care. The adult social care system could not survive without the enormous contribution of unpaid carers who provide vital support for thousands of people every day.
• Increased care worker pay – including one-off increases and/or retention bonuses – will help tackle the serious recruitment and retention issues facing the sector. The costs for any such increases must be met in full by genuinely new funding from central government and we look forward to working with the Government on its Fair Pay Agreement and Employment Rights Bill
• Robust commissioning arrangements must be put in place to ensure that the commissioning system does not create two tier systems and lead to disagreements between councils, the NHS and the care sector.

• The financial position of adult social care remains seriously challenging. Surveys by ADASS show that 63 per cent of councils overspent on their adult social care budgets in 2022/23. Of these, the proportion using their reserves to fund overspends increased from 37 per cent in 2021/22 to 72 per cent in 2022/23. One-off funding to service recurrent spending is unsustainable. This has very real consequences. Over 470,000 people are waiting for an assessment, a package of care or direct payment to start, or a care plan review.
• It is a similar story with the care workforce. Workforce numbers have picked up slightly (20,000 increase between 2021/22 and 2022/23) and vacancy rates have decreased to 9.9 per cent from 10.6 per cent, but the number of filled posts is still below pre-pandemic levels, and the vacancy rate remains stubbornly high. Our own research shows that there is a growing reliance on agency staff to plug gaps. This can often be more expensive, does little to properly stabilise the sector, and can impact on the continuity of care which people drawing on it rightly feel is important.
• Stabilising and supporting the care workforce must be an immediate priority. One-off increases in pay and/or retention bonuses (particularly as we look ahead to winter) would help, but we need a long-term plan for the care workforce, which includes measures to improve pay for the long-term. This needs to be positioned not just as crucial for people drawing on social care, but also crucial in terms of social care’s contribution to the economy. Skills for Care estimate that the sector contributes £55.7 billion gross value added per annum to the economy in England. Local government, and the wider care sector, needs to be appropriately engaged in the Government’s work on a Fair Pay Agreement.
• The Resolution Foundation have calculated that if a living wage for care workers was publicly funded, just under half (47 per cent) of public costs would be returned to the Exchequer through higher personal tax receipts and lower benefit payments. The Living Wage Foundation has also recently published interesting research on the real living wage in social care which should be noted.
• The strain on unpaid carers is also a real issue. Carers UK survey work shows that more carers are cutting back on hobbies and leisure activities, and more unpaid carers are struggling to make ends meet. Better support to unpaid family carers is important for people’s wellbeing, including their ability to access and remain in employment.
• Demography is a key driver of pressures, but this is not just about growing numbers of older people. From 2015/16 to 2021/22, the number of working-age adults receiving long-term care rose by 1.4 per cent, while the corresponding number of older people fell by 10 per cent. In 2021/22, councils spent roughly the same amount of money (£8.3 billion) on long-term support for both working-age adults and older people, despite many more thousands of older people being supported (529,000 older people, compared to 289,000 people of working age).

• The LGA wants to work closely in partnership with Government on plans to stabilise, strengthen and reform adult social care and support for the long-term. A Royal Commission could be a way to achieve this. But the pace of the Commission’s work will be crucial; time should not be spent diagnosing the problems and identifying solutions given so much work on these two components has already been done. Challenges and their consequences are gripping the service, people drawing on care, and the workforce, now.
• We therefore urge the Government to set a rapid timetable for the work (akin to the Hewitt Review), with clear milestones and early engagement with local government to draw on councils’ expertise and experience.
• Action is needed now, particularly if the full value of adult social care and support (and local government more generally) is to play into the immediate mission of building an NHS fit for the future. Any delay to proceedings risks further negative impacts on people drawing on care and support or people needing to do so and the workforce.

• Our current system of adult social care already marries national and local inputs. For instance, we have a national framework for eligibility and now a national system of CQC-led regulation of councils’ performance against their Care Act duties. This exists alongside delivery of care and support which is overseen locally by local government, whether that be through direct provision or commissioned services.
• Councils work extremely closely with numerous local partners to build an ecology of care and support and wellbeing that plays to the strengths of each area’s unique circumstances.
• A National Care Service (NCS) must not be seen purely in terms of what it could deliver for the NHS. Though obviously linked, we would want a NCS to take, as its starting point, full recognition of the huge value of great adult social care to people and communities. A NCS is also an opportunity to rethink how we support and improve people’s wellbeing in the wider sense. In this way, we would want to see a real emphasis on prevention and early action at the heart of plans for a NCS.
• Local government is a willing partner on all aspects of reform and stands ready to share its expertise and discuss options with the Government. Central to developing a NCS will be identifying priorities for immediate-, short-, medium- and longer-term action. Councils’ perspectives on this crucial part of the debate will be invaluable in shaping a NCS that makes the most progress most quickly. The LGA and councils should therefore be an essential partner in the design of a NCS from its outset.

• The LGA is a willing and supportive partner of all relevant national stakeholders and has enjoyed a helpful and constructive relationship with CQC throughout the development of ‘local authority assessment’. We look forward to continuing this relationship under CQC’s new chief executive, Sir Julian Hartley.
• We have previously raised concerns about the challenging timetable CQC are operating to and the difficulty of recruiting enough experienced assessment staff to meet that timetable.
• Concerns raised by Dr Penny Dash in her interim report on CQC effectiveness about the credibility and quality of assessment–cannot be ignored, CQC local authority assessment is still a very new process and building in sufficient time to reflect and learn should be seen as a valuable and natural step.
• The LGA is ready to support the regulator in its work to address the Dash review findings. The LGA already has a comprehensive peer review offer in place and has been working with a number of councils as they prepare for CQC assessment. Through this and other work, the LGA could help CQC define and describe what ‘good’ or ‘outstanding’ care looks like, as well as what different models of care could be truly classified as ‘innovative’. Sector-led improvement also helpfully plays into supporting local system accountability more broadly. This may be particularly important, depending on what happens with CQC assessment of Integrated Care Systems.
• The LGA continues to call for the ending of single-word ratings in CQC local authority assessment. From the outset, we have said that reducing such a complex and complicated service down to one word is neither possible nor desirable. With the end of OFSTED single-word ratings, it makes sense to take a similar approach in local authority assessment.

• The LGA continues to fully support the principle of protecting people from catastrophic care costs, but we recognise that Government faces difficult choices on competing priorities with limited budgets. In that context, councils will have welcomed confirmation earlier in the year that charging reform will now not be proceeding in October 2025. This would have been an extremely challenging timetable to work towards, with uncertainty about future funding for the reforms. In the future, councils need to be given as much notice as possible on whether reforms, such as these, are going ahead or not. This will aid councils’ planning work and avoid time and money being spent unnecessarily.

• It is estimated that around 16.1 million people have been or are currently an unpaid carer. It is concerning that so many unpaid carers are struggling with their finances and worrying about the future when the economic value of the support they provide is a staggering £162 billion a year. Many councils rely on, and fund, local carers organisations in the voluntary and community sector to communicate to carers. Funding pressures impact on that commissioned support for carers. GPs also have an important role to play in linking carers to their local council.
• Caring can place a real strain on individuals – emotionally, physically and financially. Carers are more likely to suffer depression, anxiety and stress and nearly two-thirds of carers have a long-standing health condition. The impact is often exacerbated by carers being unable to find the time for medical check-ups or treatment. Personal relationships can also suffer and carers are more likely to be socially excluded.
• ADASS’ Spring Survey 2023 found that 91 per cent of Directors of Adult Social Services strongly agreed or agreed that unpaid carers are coming forward with an increased level of need in their local area over the past 12 months. Furthermore, 68 per cent of Directors reported an increase in referrals relating to carer breakdown in 2022/23, an increase from 65 per cent in 2021/22. Directors ranked burnout as the number one reason that has contributed to an increase in carer breakdown over the past year.
• Enabling councils to better support the increasing numbers of unpaid carers should be a crucial part of a long-term and sustainable funding solution for social care. Additional funding will allow councils to support the increasing number of carers with a range of services including to help address specific needs, such as supporting carers of people with dementia, carers from Black and ethnic minority communities and young carers.

There have been a number of inquiries and commissions that have pointed towards a brighter future for social care, using the vision put forward by Social Care Future as a starting point, ‘We all want to live in the 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’. An incoming government must work with the sector, and crucially people who use social care services, to expand on their ambition and bring about the changes needed.

• We need a major push on prevention. An incoming government should be ambitious in looking at the case for a prevention grant with spend determined by councils to enable them to properly meet their Care Act prevention duty. This would help expand the provision of short-term care, particularly reablement which is well evidenced. It would widen the remit to include others coming into contact with adult social care who could benefit, beyond the current narrow focus on supporting hospital discharge. It would provide additional supported housing services, given the significant positive impact this has on residents’ health, wellbeing and social connections, as well as the role it plays in reducing homelessness and relieving pressures on the care, health, criminal justice and housing sectors.
• The Labour Manifesto rightly identified adult social care as being vital to ensuring that everyone can live an independent and prosperous life. Immediate investment to stabilise the here and now, and pave the way for longer-term reform, is needed. But investing in care and support must also be seen as a key enabler of delivering the Government’s mission to build an NHS that is fit for the future, particularly the move to a more preventative model of health and care. More broadly, given its scale and size, adult social care can play an important part in helping to the deliver the Government’s mission on economic growth.

Social care funding

• The Government should provide an immediate injection of funding to continue tackling the issues facing the care and support sector. This would be a downpayment on a future multi-year settlement for adult social care and would help improve current challenges, including: waiting times for assessments, commencement of care packages, and care plan reviews; unmet and under-met need; provider instability; workforce recruitment and retention pressures; and growing and unsustainable strain on unpaid carers. Such funding would also be a much-needed boost to the voluntary and community sector, bolstering local community capacity.
• The exact funding requirement for adult social care in the longer-term should be identified through a collaborative process, but we broadly support the Health Foundation’s analysis of the uplifts that would be required under the following different scenarios:
• Meet future demand: £0.6 billion by 2024/25 and £8.3 billion by 2032/33 (a 3.4 per cent a year real-terms increase).
• Meet future demand and make some improvements to access to care: £3.1 billion by 2024/25 and £11.6 billion by 2032/33 (a 4.3 per cent a year real-terms increase).
• Meet future demand and cover the full cost of care: £5.4 billion by 2024/25 and £14.6 billion by 2032/33 (a 5.1 per cent a year real-terms increase).
• Meet future demand and improve access to care and cover the full cost of care: £8.4 billion by 2024/25 and £18.4 billion by 2032/33 (a 6 per cent a year real-terms increase).
• All options for raising revenue and the approach to allocations should be on the table. In our Autumn Budget and Spending Review Submission 2024, we have recommended the following:
• All disparate funding streams for adult social care to be brought together into a single pot, allocated directly to councils and with no (or only limited) conditions, and put into the funding base to provide certainty and the ability to plan for the long-term.
• Funding to be more much more outcomes-focussed, linking back to the duties, intent and ambition of the Care Act.
• End the reliance on council tax and the social care precept as a key means for funding adult social care and instead look to national taxation. Formalise national funding for adult social care but with delivery remaining local and frame this positively (for instance fulfilling the ambitions of the legislation) rather than negatively (for instance ‘bailing out councils’).
• Explore the potential for better alignment between adult social care and the benefits system, including for instance Attendance Allowance.
• Commit to a review of NHS Continuing Healthcare.
• Consider a different funding model for younger adults and older people to reflect the different life situations faced by people aged 18-64 and those aged 65 and over.

Workforce

• With a workforce of 1.52 million, adult social care is a bigger employer than the NHS (1.43 million). As the NHS and adult social care workforces are in many senses two sides of the same coin – depending on each other to deliver person-centred care and wellbeing – it is essential that any modelling of NHS workforce supply and demand aligns with, or takes account of, projected demand for the adult social care workforce. Skills for Care have estimated that if the number of adult social care posts grows proportionally to the projected number of people aged 65+ between 2022/23 and 2035, an increase of 25 per cent (440,000 extra new posts) would be required by 2035.
• Training and recruiting additional doctors and nurses is important, but so too is ensuring that local health and care systems have a sufficient – and sufficiently mixed and skilled – care workforce including social workers and domiciliary and residential care workers, and other crucial roles which support people who need support to live independently in their own homes or in their communities.
• We welcome commitments to cutting waiting lists in, and transforming the long-term workforce of, the NHS. Adult social care continues to play an important part in mitigating demand pressures on acute hospitals through effective discharge and preventative work to keep people out of hospital in the first place. However, adult social care faces its own significant waiting lists for needs assessments, care plan reviews, and the commencement of care packages. With no comparable government-commissioned plan for adult social care, Skills for Care are leading valuable work to develop a long-term plan for the care workforce. This has the potential to be a crucial foundation for engagement with government on the issues that need to be addressed.
• Whilst the People at the Heart of Care white paper (December 2021) and the Next Steps update report (April 2023) contained important initiatives for the care workforce, the latter was widely considered across the sector as a major disappointment and a watering down of ambition of the former. This includes the former’s pledge of £500m for measures to support the care workforce being halved to £250m in the latter.
• Past governments have acknowledged that the adult social care workforce is bigger than that for the NHS, yet it has nothing comparable to the NHS Workforce Plan. This creates a problem of presentational parity. The future requirements of and for the social care workforce should be a far more prominent consideration for government, both as a standalone priority and in respect of its links with NHS workforce planning. We need a new deal for the care workforce and Skills for Care’s development of a workforce strategy will be key to this.
• Clear priorities which must be included in a national workforce strategy for adult social care are: staff recognition, value and reward; investment in training, qualification and support; career pathways and development; building and enhancing equality, diversity and inclusion in the workforce; effective workforce planning across the whole social care workforce; and expansion of the workforce in roles which are designed in coproduction with people who draw on care and support, and in roles which enable prevention and support the growth of innovative models of support.
• Improving the pay, conditions and development opportunities of the care workforce is crucial for addressing long-standing recruitment and retention challenges for the benefit of people who draw on care and support, workers and our health service. The LGA notes that whilst the National Living Wage (NLW) increase announced in the Autumn Statement is of course great for care workers, it is challenging for councils’ adult social care budgets given that providers will understandably expect to see their fees increase to absorb the NLW increase.
• While not part of the paid workforce, we also recognise the invaluable role that unpaid carers and volunteers play in supporting people to live the lives that they want to live in their own homes and communities. There is ample evidence of the growing strain on unpaid carers, with many suffering ‘carer burnout’. This is troubling in itself but also risks compounding pressures on the paid workforce.
• We owe an enormous debt of gratitude to our frontline care workforce who give so much in supporting people of all ages who have cause to draw on social care. We want to see social care presented as being about ‘all of us’, not ‘them and us’. It needs to invoke shared values, such as caring about each other, rather than, for instance, ‘looking after our most vulnerable’. Similarly, we need all voices in the debate to frame social care as an investment and an opportunity, rather than a cost and a problem to be fixed.
• The LGA’s May 2024 publication on The Care Act 2014: Ten years on from Royal Assent provides a number of articles including from Skills for Care and, crucially, the social care workforce and organisations which represent them. The workforce is fundamentally important to the delivery of the Care Act’s aims, yet faces serious challenges such as on recruitment and retention, skill gaps, and morale. The articles helpfully identify what is needed to develop, build and support the social care workforce of the future.
• One of the LGA’s recommendations in the publication is that there must be recognition of there being no such thing as a ‘standard care worker’ and develop a comprehensive long-term plan for the care workforce, building on the important work that Skills for Care are leading on and which we know will be an invaluable contribution to the debate. A long-term plan must include a thorough review of care worker pay and conditions, with corresponding increases and improvements respectively. In the short-term, explore the case for one-off increases in pay, and/or retention bonuses, particularly as we head into winter.

For further information on this briefing, please contact: [email protected]