Reform in the health and social care sector

1. A growing and ageing population that will shortly render the existing social care model obsolete. The ONS estimates that there will be an additional 5.8 million people aged 65 and over by 2041. This, compounded by the increasing rate of people admitted to hospital with longer-term and complex health needs, does not bode well for an industry already being pushed to its limits by chronic underfunding and the COVID-19 pandemic.
2. Growing financial pressures on local authorities leading to significant staffing turnover rates, calling into question, in the words of the Health and Social Committee, ‘the long-term sustainability of the workforce’.
3. Disjointed, siloed service provision resulting in a fragmented care offer, a lack of uniformity across the country (a so-called ‘postcode lottery’), and needless duplication of services. Such fragmentation leads to people being ‘passed from pillar to post’, disengagement with services, and ultimately poorer outcomes.
4. COVID-19 accelerating and exacerbating existing issues. There have been more than 30,500 excess deaths in the care home sector alone, as well as over 4,500 deaths in domiciliary care services, indicating a sector left uniquely unsupported by central government, with care staff disproportionately affected by the pandemic.

The first two factors are difficulties that care providers can do little to alleviate without wider legislation and support from central government and commissioning bodies. One solution to the problem of an ageing population is health and social care models that focus on prevention and early intervention. The growth over the past ten years of enablement programmes in domiciliary care is just one example of this. However, as the supply of these models is outstripped by demand, the locus for dealing with an ageing population will inevitably become funding.

Additional funding, on top of usual adult social care spend, has been settled for the 2021/22 financial year and includes:

• An additional £300 million for adult and children’s social care, with local authorities allocating as best fits with the local context
• An additional £1 billion announced at the 2019 spending review, maintained for this year and every consecutive year until the end of this parliament
• A 3% adult social care precept that councils will be able to levy – in essence, this is their ability to increase their share of council tax
• £2.1 billion to local authorities through the improved Better Care Fund.

While promising, this falls short of the requirements for adult social care funding as set out by the Health and Social Care Committee, which called for ‘an increase in annual funding of £3.9 billion by 2023/24’ as a starting point, adding, ‘further funding is required as a matter of urgency [to] address shortfalls in the quality of care currently provided, reverse the decline in access [and] stop the market retreating to providing only for self-payers’. This, however, is not unique to social care budgets and is represented across other local authority service sector areas.

While we wait for further funding to be injected into the system, care providers should ensure cost-effective services that continue to deliver high quality through a range of measures. This can include the continued delivery of preventative care to reduce hospitalisation, low-level interventions that are proven to save money (e.g. providing elderly people with slippers to prevent falls), the use of data to drive continuous service improvement and target interventions where most appropriate, and the recruitment of local people to deliver care, reducing mileage costs. As a care provider, demonstrating to commissioning bodies that you are mindful of cost-effective practices without sacrificing the quality of the services you deliver will be of paramount importance when submitting bids.

The last two factors – disjointed services and COVID-19 – are obvious areas for proactivity for health and social care organisations. Let us turn to these to analyse reform proposals for each, and what this may mean for providers tendering to deliver health and social care services.

Disjointed, siloed service provision

According to research published by the House of Commons Library, the adult social care workforce comprises 1.52 million people (there are approximately 1.3 million working for the NHS) working for approximately 18,200 organisations with roles spread across the private, public, and voluntary sectors. This produces levels of market volatility unsuited to the delivery of care and with serious consequences for providers, care users, and the care workers alike. As the King’s Fund points out, this includes:

• A lack of public understanding, service availability and choice for those accessing care with an undersupply of services in some parts of England
• High rates of providers ‘going bust’ or leaving the market affecting continuity of care
• Inconsistent quality of care – one in six falls below the standard required by the CQC
• High turnover and vacancy rates – the industry struggles to compete on employment standards.

These have become endemic in the sector and are compounded by the gulf between NHS and adult social care service systems.

Deeper integration of systems at a local and national level are touted as, if not a panacea, a step towards structurally improving the health and social care sector. Integration and innovation in the sector are the subject of the government’s white paper published in February 2021, which states the case for ‘greater collaboration between the NHS and local government, as well as wider delivery partners, to deliver improved outcomes to health and wellbeing for local people’. It points out that integration has already started to pay dividends:

Integrating care has meant more people are seeing the benefits of joined up care between GPs, home care and care homes, community health services, hospitals and mental health services. For staff, it has enabled them to work outside of organisational silos, deliver more user-centred and personalised approaches to care, and tackle bureaucracy standing in the way of providing the best care for people [and] enables greater ambition on tackling health inequalities and the wider determinants of health – issues which no one part of the system can address alone.

This is in large part due to local authorities pre-empting legislative reform to integrate services and systems through joint-commissioning processes, pooling resources and requiring providers to buy into whole-system approaches that focus on wider community wellbeing outcomes.

The white paper proposes to go one step further and put integrated care systems (ICSs) on a statutory footing. ICSs are partnerships that bring together commissioners and providers of NHS services with local authorities and other local partners to collaboratively plan their health and social care systems based on the needs of their local populations.

These are of varying sizes and with different arrangements in place, and are currently split between 42 areas across the whole of England. Putting these on a statutory footing will increase the transparency and accountability of ICSs, rationalise decision-making arrangements across the country, and encourage deeper integration of NHS bodies with local authorities and their partners. This may be successfully legislated for by 2022.

What does this mean for care providers?

Many providers are already working closely with NHS bodies, particularly where their services are bought by CCGs and local authorities via joint-commissioning processes, with KPIs and outcomes related to wider community health and wellbeing benefits. Preparing care services to deliver on community-wide benefits, with associated KPIs, may ensure a more seamless transition once ICSs come into play.

Operating IT systems that can interact with external systems will be a key factor in the delivery of a collaborative approach. Proactive partnership building with statutory agencies, private care providers, and the VCSE sector will provide a platform from which organisations bidding to deliver services can demonstrate their readiness and willingness to work with partners across their communities. And, perhaps most importantly, working closely with professionals across your local health and social care network will support a two-way approach to integration, and avoid the possibility of becoming a junior partner in the collaborative process.

COVID-19 and care staff

It is widely accepted that the sector was failed by central government. The Public Accounts Committee stated that, ‘Years of inattention, funding cuts and delayed reforms have been compounded by the Government’s slow, inconsistent and, at times, negligent approach to giving the sector the support it needed during the pandemic.’ The committee was particularly excoriating in its assessment of the government’s failure to provide the sector with adequate levels of PPE and testing for staff and volunteers. This, coupled with an almost month-long delay to the publication of the adult social care action plan on 15 April 2020, had disastrous consequences both for those accessing care and for the mental health and wellbeing of staff.

And now, what is to be done? The Care Quality Commission, in its State of Care 2019/20 report, observed:

Social care’s longstanding need for reform, investment and workforce planning has been thrown into stark relief by the pandemic. There needs to be a new deal for the adult social care workforce that reaches across health and care – one that develops clear career progression, secures the right skills for the sector, better recognises and values staff, invests in their training and supports appropriate professionalisation.

The CQC’s focus on improving recognition, progression, and security for staff is not reflected in the white paper. However, the Health and Social Care Committee has published recommendations related to the social care workforce prior to the publication of the white paper. The ‘Social Care: funding and workforce’ report, published in October 2020, outlined five key areas for future legislation in the wake of the pandemic:

1. Improving the recognition afforded to social care staff to safeguard the future of the workforce
2. Reforming how people pay for care in a manner that provides a sustainable basis for continued pay rises above increases to the National Minimum Wage and in line with NHS pay increases
3. Improving employment conditions across the sector, reducing the reliance on zero hours contracts, and improving the provision of sick pay
4. Streamlining of training for social care workers to improve routes of entry to the profession and improve care progression for existing workers
5. Ensuring ‘transitional arrangements’ are in place so social care workers can be recruited from overseas until there is sufficient resilience built up in the domestic supply of social care workers.

How should care providers tendering for services respond to such recommendations and imminent changes to legislation?

There is no simple answer and most if not all providers are already responding to the perpetual issue of staff recruitment and retention. With a vacancy rate three times the general labour market average, care providers are implementing values-based recruitment, requiring candidates to describe their suitability for the job as it relates to their outlook and drive to deliver high quality care, rather than based solely on their qualifications. Operating your own bespoke training programme, utilising local providers of care, provides staff with a solid grounding in health and social care as well as building up their knowledge of available local providers to ensure joint-working practices.

Where zero hours contracts are used, ensure that this is based on what your staff want, established via staff surveys. Flexible working can be an attractive offer to some staff, particularly those with care responsibilities outside work. However, fixed hours are increasingly sought by commissioning bodies.

Recognition schemes to improve retention should have meaningful outcomes and engage staff. Any care provider that can demonstrate a turnover rate close to the UK average (this is 15% across all sectors but 31% for the social care sector), will be favourably scored by commissioning bodies.

The key point is to show commissioning bodies (local authorities, CCGs, or other commissioning authorities) that your recruitment processes, training programmes, and retention schemes contribute towards a primary focus on the delivery of services and care continuity for those accessing services.