- PAC calls for urgent short-term action on social care to ensure equality with NHS.
- Government response was ‘slow, inconsistent and at times negligent’, as NHS was not co-ordinated with social care.
- Current system failed those who needed it most and lessons must be learned before any second wave hits.
- Committee demands improved social care funding, clear responsibilities and accountability.
- Social Care in the UK is not fit for 21st Century and urgent radical reform must be introduced.
The Commons Public Accounts Committee’s last report of this Parliamentary Session is a damning indictment of the treatment of Britain’s most vulnerable, frail and elderly citizens. The PAC is demanding Government report back within the next few weeks, on how it proposes to improve the way the NHS and Social Care operate, enhance co-ordination between the sectors and draw up its plans to prepare for a possible second wave of Covid-19 cases in coming months.
The failings identified
Committee criticises Government response as ‘slow, inconsistent and at times negligent’: The Committee rightly highlights the failings of the social care system and the negligence of the NHS instructions to free up hospital beds, including sending 25,000 elderly people back to care homes, regardless of whether or not they had coronavirus. The hospitals forced homes to take patients (sometimes under threat of withdrawing council funding if they refused), without checking whether they were equipped with sufficient PPE or isolation facilities and training. This careless disregard for the conditions of the staff and other residents in care settings, along with the refusal to admit or keep elderly patients in hospital, undoubtedly put thousands of lives at risk. The staff in care homes were left unprotected, they and other residents became infected and the impact on the social care sector has been catastrophic.
Lack of transparency around funding for hospitals, social care, PPE supply and testing: The Report requires Government to report to the Committee by September, to provide the basic information that it was unable to give the PAC, including its arrangements for funding contracts with private hospitals, testing and PPE sourcing. In addition, by October, the committee wants the DHSC to set out, in writing ‘what it will be doing, organisationally, legislatively and financially, and by when, to make sure the needs of social care are given as much weight as those of the NHS in future.’
Successive Governments have promised reform, but never delivered: The social care failings which have caused so many potentially unnecessary deaths, are the result of decades of neglect of social care. Royal Commissions, White Papers, Reviews and even legislation have resulted in no radical changes, and in the meantime more people who need care have been left without.
The lessons to be learned in case of second wave:
DHSC should consider social care as part of the health system, rather than as a stand-alone function in the private sector: The PAC rightly lambasts the DHSC for treating social care as a second-rate service, protecting the NHS system while neglecting the needs of patients who rely on care homes or homecare and those providing that care. It says that Government must draw up plans to recognise that social care and NHS are two parts of a single system which needs to be adequately funded and where there is clear accountability for the outcomes. Whether someone has cancer or dementia, both have health problems and both need care. To consider them differently makes no sense. Currently, NHS has no direct responsibility for social care. The separation of budgets and care delivery resulted in hospitals and even doctors withdrawing care for elderly, frail patients, in the middle of a health emergency to which those very patients were most vulnerable. The responsibility for those in social care falls under many different organisations and this urgently needs to be streamlined, so that there is a clear line of responsibility.
Discharging people without ensuring it was safe to do so, must never happen again: Nightingale Hospitals had spare capacity all the time, private hospitals had also been commandeered, yet it was considered acceptable to send people back to care homes, to infect staff and other residents, regardless of whether they had Covid-19. Even in April, when the official guidance was changed to require any patients to be tested for Covid-19 before being returned or sent to a care home, this same guidance stated that the result did not have to be received before they were discharged. Given the knowledge of asymptomatic spread and the lack of inspection to ensure each care home had adequate facilities for isolation and protection of both staff and residents, this prolonged the risk that the virus would be transmitted into social care by the NHS. If the NHS and social care were under the same responsibility, hospitals and doctors could not just ‘get rid of’ patients in this way.
GP services must not be withdrawn in any second wave: Withdrawal of GP services from care homes, as happened in the early stages of the pandemic, risked many residents suffering other life-threatening illnesses which went undetected. It is important that, in future, there is a recognition that all lives are precious and just because someone is under the responsibility of the social care system, rather than the health system, should not mean they are relegated to second class status. Nobody would imagine that a patient in hospital would be denied a doctor, yet that same person could be in a care home and unable to get a GP visit. If care homes are being asked to act as substitute medical facilities, they must have equal support to the NHS.
Government should ensure increased funding for social care does reach care providers: The funding of social care has been left to cash-strapped councils. Government distributed £3.2bn to councils to help with Covid pressures ‘including social care’ – and it was not until 15 May that £600m was allocated for infection control in care homes – but much of that money did not reach the care sector. Councils have used the money for other purposes or added it to reserves. There is an overall lack of accountability for social care, which the PAC rightly says needs to be urgently addressed.
My suggestions for urgent reform:
This is a multi-faceted problem, with so many elements involved, that there is no single solution. Every aspect of the care system is under pressure – from funding, to delivery, to prevention, to homecare and care homes. It is clearly socially unjust to ensure free care for people, regardless of means, only if they qualify for the NHS, while imposing exceptional costs on those very people who also need care because of poor health, but do not qualify for the NHS. At the moment, there is no money set aside for long term funding of social care. These are the headline measures that I believe Government will need to be considering:
Government must ensure there is a long-term funding plan to meet care costs of the aging population: At the moment, there is no structure for money to be earmarked for future care needs, not by local or central Government, nor by individuals. Funding is allocated at the point of need, but if there is not enough money then the people who suffer are the individuals who need care. Therefore, there should be a taxpayer funded system, which recognises that society has a duty to look after its population and there is no justification for the arbitrary distinction between different illnesses that we currently use.
Central Government and Local Government will need taxpayer funding for social insurance, so everyone pays towards later life care, whether or not they need it: Tax will have to be collected – whether this is called a ‘care contribution’ or ‘care insurance’ or some other name, it should be paid on a similar basis for everyone. Taxpayers cannot cover the entire cost, but can provide basic care, in return for a lifetime contribution to cover future costs. This could lead to a system of free basic care for everyone, as we offer in Scotland and in the NHS, or a system of co-payments that require people who are able to do so to pay, say, 50% of the cost up to a maximum lifetime amount. Ideally, this should be throughout life and part of the tax system, or identified as a separate ‘care contribution’ as a percentage of income or wealth.
Private sector care home operators who are financially fragile need to be required to improve their financial resilience: Many private sector care providers are in financial trouble. Indeed, they were facing difficulties before the pandemic, but that has become far more acute. The Government and Regulators do not currently have powers to require these homes to improve their funding, but this is something that is long overdue. Heavily indebted providers and offshore structures should not be permitted and if that requires Government taking over some providers, it may be the best of otherwise unpalatable options. The neglect of the sector by the NHS and central Government, coupled with the council care means-test, results in care home residents paying huge sums for care that seems to neglect their needs. But it is also important to address the underlying problem that councils do not pay enough to cover the costs of care. Bringing the care sector into the funding umbrella of the NHS would help resolve some of these issues.
New immigration rules to allow health workers special visas must include provision for social care: With over 120,000 vacancies in the care sector and the low pay levels of staff, the new immigration rules would prevent recruitment of any overseas care staff. It is all very well to hope that UK workers will fill these positions, but the likelihood is that insufficient numbers can be recruited and, in the meantime, that would leave those needing care without the staff required to meet their needs. The frail, vulnerable people cannot just wait until the sector finds home-grown workers. A transitional arrangement is urgently required to allow overseas care staff to come to the UK.
Encourage individuals to set aside funding for later life care – via Care ISAs or Care Pensions or national equity release schemes: Currently, over 6 million older people have ISAs, each worth on average around £40,000 and millions more have pension funds. Before these people spend all this money, Government has an opportunity to introduce new incentives to encourage them not to touch the funds and keep them for their 80s or 90s, in case they need to pay for care, beyond that which the Government can provide. As with pensions, taxpayers only offer a basic pension (the lowest in the developed world) and spends billions of pounds each year to encourage individuals to build private funds to top up the basic state provision. The same principle could be applied to funding care. Pensions are not the only money needed during retirement. Employers could be encouraged to pay into care funds for younger people, but for those babyboomers now entering their 70s that is no longer an option. However, many of them have ISAs, homes or private pensions that could offer a source of funds to top up basic state care in later life.
Second wave must not repeat the mistakes: Urgent social care reform is long overdue – and there are options for improving the system with cross party support. This must no longer be a political football. Our national health emergency response failed those relying on social care, in order to protect others who might need NHS healthcare. That distinction must not drive thinking in any second wave of the pandemic. Equal treatment for NHS or social care is vital.