The APPG on Adult Social Care – Oral Evidence Session - 10th June 2019
A Record of the minutes for the APPG Meeting Committee Room 20, The Palace of Westminster Monday 10th June 2019, 2pm-4pm
Chair
Lord Colin MacKenzie Low of Dalston CBE is a crossbench peer and joined the House of Lords in 2006.
Guest Speakers
Richard Kemp CBE - Deputy Chair of the Community Wellbeing Board at the Local Government Association of England & Wales
Steve Scown - Chief Executive at Dimensions
Jane Ashcroft CBE - Chief Executive Officer at Anchor Hanover
Vic Rayner - Executive Director at National Care Forum
Isaac Samuels - Member of National Co-production Advisory Group at Think Local Act Personal
John Dixon - Partnership and Development Manager at RNIB
Jane Harris - Director of External Affairs and Social Change at National Autistic Society
James Bullion - Vice-President at ADASS
Others in Attendance
Stephen Lloyd MP (Independent, Eastbourne)
Sara Petela - PB Consulting
Peter Hand PB - Consulting
Emma Turnbull - PB Consulting
James Tuck - PB Consulting
Sector witnesses
Overview
Lord Low (Crossbench) began the session by introducing himself as the Vice-Chair of the newly-formed APPG on Adult Social Care (ASC), and explained that the enquiry had been sent up in response to the delay of the expected Green Paper, to get the views of a range of stakeholders including commissioners, providers, and users of ASC.
The enquiry and APPG have been set up to raise awareness of ASC for those who use it, to attract people to develop careers in the sector, and provide parity with the provision for healthcare services.
Richard Kemp (Deputy Chair of the Community Wellbeing Board at the Local Government Association of England & Wales) then gave the first statement of the session, highlighting the current lack of optimism surrounding the ASC Green Paper, and suggesting that his belief was that the paper wasn’t even fully written yet. He commented that the last major publication into the issue was the Dilnot report seven years ago in 2012, and none of the suggestions from this report had been fully implemented into government policy. Until there is a clear discussion on funding, all other discussions on ASC will fail to materialise into much action.
Richard then explained that whilst the NHS is moving towards a culture of prevention rather than cure, ASC was struggling to make this change. This problem is being further complicated by the delay of the comprehensive spending review, and the fact that Richard believes there is no proper information or effective planning from government.
The final part of Richard’s evidence focused on the workforce pressures in the system, with there being a 100,000 personnel shortfall in the sector. These pressures are also far greater in London and the South East due to the comparatively higher cost of living putting people off from the career, Richard also highlighted that social care providers had been having to hand back contracts due to not having the staff capacity to fulfil them.
Lord Low then led questions from the panel, asking whether Richard felt that planning for ASC provision was being taken ‘in the dark’, to which he agreed and said they were being taken in desperation. Although no individual had not been given a replacement provider, the handing back of contracts has been straining the system to breaking point. Following this, Stephen Lloyd MP (Independent, Eastbourne) agreed with Richard that currently we can’t plan for these shortfalls, and that he was meeting with constituents later that day where the local nursing team and ASC providers were working out of the same office together. He then asked Richard what the ideal model of ASC would look like in his area. Richard suggested that the most important thing was how it was commissioned, with a seamless system where the patient does not see the difference between care from different providers. He also pointed out that there is a large disparity in the requirements for care for those who have got to retirement age in reasonable health and those who begin to experience problems in their 40’s. This highlighted the need for care planning to begin before people reach retirement or start to suffer in their quality of life.
Lord Low then asked if the ASC service had the required skills to deliver on the ground. Richard explained that the current turnover rate for staffing in the sector was 30%, and that is was common for employees to be trained in the system before being ‘pinched’ by the NHS. He also added that the health service and councils need to take ASC into greater consideration, providing the example that the cost of providing green spaces for people to help with their mental health would be negligible compared to the cost of providing hospital care. Lord Low questioned if this was simply a matter of resources to which Richard partly agreed, but also suggested that there was money in the system not being used to its maximum potential. Stephen added that until ASC gets the same ‘clout’ as the health service, budgets will always be squeezed, and that the government needs to recognise that other sectors than the NHS require money as well.
After a brief break, Steve Scown (Chief Executive at Dimensions) then gave evidence on public awareness of issues in ASC, adding that the recent BBC Panorama documentaries on Whorlton Hall had added a further negative narrative to the discussion. The system unquestionably requires more money, with social care employing roughly as the NHS. Another issue that influences public perception is politicians referring to these jobs as ‘unskilled’. He rounded off his speech by highlighting that social care gets 10% of the funding of the NHS, and that although there was hope in the form of this APPG, social care is simply not on the horizon of politicians.
Jane Ashcroft (Chief Executive Officer at Anchor Hanover) then gave evidence on the provision of care homes and retirement housing for older people, outlining the opportunities and challenges. Technology provides many opportunities, with voice recognition offering options to support the delivery of care. Jane then suggested that the continuing uncertainty about funding reform for the care system was one of the biggest challenges. The lack of a clear direction of travel on funding reform makes decisions on investment difficult to make. She outlined that there are roughly 10,500 employees employed by Anchor Hanover, and that establishing a skilled workforce was key to delivering to residents’ individual needs.
Jane then went on to explain that Your Care Rating is the largest and most authoritative survey of care home residents in the UK. This offers residents and their families the opportunity to rate the quality of service regularly and can support the work of the Care Quality Commission’s inspection process. In terms of the workforce, she recognised there were significant challenges and discussed many of the ways in which Anchor Hanover works to ensure it recruits and retains great people. This includes paying above the National Living Wage, providing a structured approach to career development and ample opportunities for training.
Then Vic Rayner (Executive Director at National Care Forum) then spoke about the changing environment of the sector. She explained that there are currently 22,000 providers of social care varying in size, and that due to this the transfer of ideas from one provider to another was difficult. Technology can play a huge part of the sector’s future to improve efficiency and productivity gains. Digitalisation of the NHS has received around £200 million in funding, whilst social care only received £23 million. She explained this has left social care without the infrastructure for future adoption, which the NHS has. Vic highlighted that the total contribution of social care to society is £38.5 billion. Finally she told of the future challenges that social care will face, such as the rising BAME elderly population which currently stands at 1.5 million people.
Lord Low opening the discussion by asking what proportion of patients were self-funders, which Vic answered by saying roughly 50%, with it being an almost equal split between fully self-funders, part state-funded, and fully state-funded. Sara Petela (PB Consulting) then asked further about the opportunities for technology. Steve provided an example of a provider working with a college in the US around wrist-worn gadgets that measure temperature, pulse rate, behaviour, and other figures. He explained that this does not happen more often as normally the cost of research falls on the provider, who are already struggling for money. Vic added that in only 15-20% of all care homes use electronic care planning systems, meaning that lots of very useful data is being lost through paper copies. Jane commented that in her experience although electronic care planning was a better system, it is too costly to implement currently and would cost billions nationally.
Stephen then requested more information on the Your Care Rating project from Jane, where she explained that it had been developed by IPSOS in response to only 4% of care homes rated as outstanding. Currently 16 providers use it, and they are able to analyse responses on a home-by-home basis. Vic then added that the 4% figure related to the disparity in regulation provision and content from the regulator, and Steve commented that it wasn’t necessarily a money problem, but instead down to how the regulator judges what they witness during inspections.
Lord Low questioned what the impact of tightening the eligibility criteria had been. Steve responded by explain that the people with 24/7 care hadn’t been affected too much, but those receiving 4/5 hours of care a week had seen this roughly halved. Jane added this delayed the process of moving patients from an acute setting to a domiciliary setting. After this Lord Low also questioned about what the key challenges in the sector are. Jane replied with workforce capacity, numbers, and skills, and Steve explained how the sector is competing with much easier jobs for workforce.
Lord Low’s final question was what one change each speaker would make and why. Vic suggested that there needs to be a shared vision in the sector about how to move forward, Steve commented that the social care brand had to be valued as much as the NHS, and Jane thought the funding needs for the transition had to be recognised greater.
The next session opened with Isaac Samuels (Member of National Co-production Advisory Group at Think Local Act Personal) speaking about how the majority of the people he comes across are petrified by the thought of having to go into the care system. He explained that there needs to be an integrated approach with other areas of society such as education and employment, so that people who use the services have an elevated platform to shape the future of these services.
There is also a false notion of independent living for lots of people who require ASC, with many people often going days without seeing anybody else. Money gets spent on agency staff that could be used to connect people Isaac argued. Staff in the sector get paid terribly for the work that they do, and he said that people need to be paid well, trained, and feel like they are being recognised for making a difference. Isaac felt that there needs to be a wider conversation between the people who access the services and those who commission it, so that there can be greater personalisation of care provision.
Next up John Dixon (Partnership and Development Manager at RNIB) spoke about provision and resources in the sector, referring the results of a 2016 survey which told of a significant reduction in provision for ASC. In particular, John spoke about people who had recently lost their sight also losing their job whilst waiting for social care help. There has been an increasing tendency for generic services that are not tailored to the specific needs of the individual, partly because the people providing assessment are not appropriately trained to do the job.
Jane Harris (Director of External Affairs and Social Change at National Autistic Society) rounded off the trio of speeches by talking about autism and social care, highlighting that 70% of autistic people also have another disability, and that they have 4 times the rate of social isolation. She told of stories of autistic people being sectioned under the Mental Health Act, simply because they aren’t getting the social care support. Often staff lack the required specific training that autistic people require. In a recent survey only 17% of local authorities rated themselves as green on whether autism training was even available. Jane rounded her speech off by saying that commissioners often only care for the safety of autistic people at some points rather than helping them to flourish.
Sara then began the questioning by asking what could be done to ensure the user’s voices could be heard. Isaac answered by suggesting non-generic approaches had to be used, as often people were being kept at bay from having assessments due to specific needs. He added that typically those who get the most help from services were those who shouted the loudest. Patients from minority backgrounds are also less likely to get an assessment, and the spaces required are often unsuitable for those trying to access them. Isaac explained that care had to change and that technology and data were integral to providing a more personalised service to patients, and keep them from the fear of having their support taken away.
Lord Low then asking the panellists if they thought that the social care system allowed people to live an independent life. Isaac answered again by saying that sometimes yes, but most of the time no, especially in home care services. Lord Low asked if there were some examples of excellence the committee could hear. Jane explained that in Cambridgeshire there is a specific team that provides assessment for autistic patients requiring ASC. This however was a rarity, and there is a culture of social workers feeling pressured to judge people as not needing to receive care due to budgetary restraints. Finally Lord Low asked what one change should be made to ASC. Jane replied that funding should be based on an assessment of needs. John thought that pooling risk in local government was important, and that things hadn’t moved on in the sector in 10 years. He also explained that a vision rehab project in Sussex, which cost £900,000, had cost offsets of £3.2 million, demonstrating this as a cost-effective way of providing ASC.
The final statement came from James Bullion (Vice-President at ADASS), who began by saying that the current model of ASC is not suitable for the needs of those using its services. The system is overly complex and has too much ambiguity. He added that it is currently unclear who pays for care, and that there is a mismatch between accommodation and care needs. Despite this he thought that not everything was bad, and that in the Care Act there is plenty of good legislation, whilst the user-led movement was also positive.
James went on to add that there needs to be an increasing understanding from local authorities over the opportunities for prevention. Currently the sector is at a crossroads between the impending green paper, and the contrast with the NHS. However, there is still an opportunity to build on integration and work with service users to develop ASC. This would require the plugging of the current shortfall in funding for the sector, estimated at about £3.5 billion. As a result of this, more than 100 areas have experience of contracts being handed back, affecting roughly 5,500. Staff turnover also stands at 30%, with 650,000 social care workers needed, which equates to the same amount as practically every single school leaver this year. James rounded off his speech by saying that local authorities needed to show local leadership, in order for ASC to focus on prevention rather than cure.
Sara opened questions by asking what opportunities there were for integration with the NHS Long Term Plan. James answered by saying that the logic models used were well suited to working with social services. He added that GPs have the name of those at risk before local authorities do, and that often that older people arrive into the system 5/6 years too late. Sara then asked what changes would speed up the referral process, to which James answered that social workers should be co-located with community health staff and prescribers, and those who aren’t quite ready for ASC can work with providers to develop long-term plans. He then went on to add that social prescribing offered a big opportunity, especially around housing and relationship issues. Finally Sara asked what one change should be made to ASC, which James answered that the culture surrounding ASC needed to change, and become more based on community based social work.
Lord Low concluded proceedings by covering a summary of the sessions points, before bringing the session to an end.