The adult social care market in England
25 Mar 2021 02:51 PM
Short-term funding and the lack of a long-term vision has hampered planning, innovation and investment in adult social care. The current accountability and oversight arrangements are ineffective for overseeing the care market, according to a report by the National Audit Office.
The adult social care market in England
The Department of Health & Social Care (the Department) is responsible for setting national policy for adult social care and for the overall performance of the care system. The Care Act 2014 places a range of duties on local authorities. Under the Act, local authorities are responsible for commissioning adult social care from around 14,800 registered providers, most of whom are independent. In 2019-20, local authorities spent a net £16.5 billion on care. The Ministry of Housing, Communities & Local Government oversees the distribution of funding to local government and the financial framework within which local authorities operate. The Care Quality Commission (CQC) regulates care providers for quality and oversees the financial resilience of the largest and potentially most difficult to replace providers.
Current accountability and oversight arrangements for adult social care are ineffective. Although the CQC rates most care as good, the Department lacks visibility of how effectively local authorities commission care and the outcomes achieved. It has no legal powers to intervene or hold individual authorities to account. This limits the Department’s ability to assess how well money is being spent, or what additional funding is needed to support care users. The Department has increased its focus on adult social care in response to COVID-19; it has taken steps to increase its capacity and address data gaps, and in February 2021 published a white paper with proposals to improve the data it collects and its oversight of local authority delivery of social care.
The Department has not met previous commitments to tackle recruitment and retention challenges for the 1.5 million people who work in care. It has not produced a workforce strategy since 2009, despite committing to do so in 2018. The Department told the NAO that a workforce strategy would be dependent on the next spending review and wider reforms committed to in the recent white paper.
The Department does not have a clear strategy to develop accommodation for adults with care needs and does not monitor the condition of current accommodation itself. Uncertainty about future funding and care policy mean providers are reluctant to invest in accommodation. Funding for new investment is ad-hoc with no co-ordinated, long-term vision across government about how new accommodation will be developed or existing accommodation adapted to meet care needs.
Short-term funding settlements have hampered long-term planning for adult social care. The NAO has previously emphasised the importance of clarity over funding beyond the end of a spending review.1 Uncertainty has made it difficult for local authorities, facing significant financial pressures, to plan how much care they could purchase beyond the current financial year, constraining much needed innovation and investment. For 2019-20, the Department assessed that most local authorities pay care providers below a sustainable rate for care.
Stakeholders lack visibility of provider finances across the care market. Pre-COVID-19, many care providers were not financially resilient, and the impact of COVID-19 could have further consequences. In view of local authority responsibilities for care and CQC’s market oversight role, the Department does not collect additional information on provider finances. Analysis by CQC of the large providers indicates that government support has helped to stabilise the market. Falls in occupancy from around 90% pre-pandemic to 80% in February 2021, raises concerns that ongoing support may be required.
In 2019-20, 839,000 adults accessed long-term support arranged by local authorities. Pre-COVID-19, Carers UK estimated there were around 7.3 million unpaid carers in England.2 Around 24% of adults aged 65 and over have unmet care needs.3
There are likely to be large increases in future demand for care, leading to rising costs. The Department projects that around 29% more adults aged 18 to 64 and 57% more adults aged 65 and over will require care in 2038 compared to 2018. Over this period, the total cost of care is projected to rise by 90% for adults aged 18 to 64, and 106% for adults aged 65 and over. These projections are highly uncertain and will also depend upon any changes to the way care is delivered, which the Department has not yet assessed.
Despite many years of government papers, consultations and reviews, the Department has not brought forward a long-term plan for care. The pandemic has delayed promised reforms as government prioritises the COVID-19 response. The Department will be leading reform plans and has committed to bringing forward proposals in 2021. Reforming the sector will be a significant challenge and will need a whole system, cross-government approach.
“The lack of a long-term vision for adult social care coupled with ineffective oversight of the system means people may not get the care that best supports them.
"The Department of Health and Social Care has increased its focus on adult social care in response to the COVID-19 pandemic. It needs to build on this to ensure that its long-awaited reforms deliver affordable, high quality and sustainable adult social care for the future.”
Gareth Davies, the head of the NAO
Notes for Editors
- In our 2018 report on Financial sustainability of local authorities 2018, we recommended the Ministry of Housing, Communities & Local Government develop a long-term, financially sustainable plan for local government that addresses current financial and demand pressures
- Carers UK: Juggling work and unpaid care, 2019.
- The Health Survey England: In 2018, the latest year for which there are published data, 24% of adults aged 65 and over surveyed said they had some unmet need for an activity of daily living for which they did not receive support.
- Press notices and reports are available from the date of publication on the NAO website. Hard copies can be obtained by using the relevant links on our website.
About the NAO
The National Audit Office (NAO) scrutinises public spending for Parliament and is independent of government and the civil service. It helps Parliament hold government to account and it use its insights to help people who manage and govern public bodies improve public services.
The Comptroller and Auditor General (C&AG), Gareth Davies, is an Officer of the House of Commons and leads the NAO. The NAO audits the financial accounts of departments and other public bodies. It also examines and report on the value for money of how public money has been spent.
In 2019, the NAO’s work led to a positive financial impact through reduced costs, improved service delivery, or other benefits to citizens, of £1.1 billion.
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