National Audit Office Value for Money Report on Adult Social Care in England, 25 March 2021
United Kingdom Homecare Association (UKHCA) welcomes the National Audit Office (NAO) report and recommendations on the adult social care market in England. We strongly agree with the need for: (a) a vision for support and care for older and disabled people; and (b) a workforce strategy.
In business, it is typical to develop a strategy before seeking investment. We therefore disagree with the Department of Health and Social Care’s (DHSC) assertion that they cannot progress with work on this agenda before a decision is made on funding.
The NAO highlights that homecare has held up well during the COVID-19 pandemic. Whilst we have seen growth as high as 20-30 per cent over the last year in parts of the private pay homecare market, it is a different story for state-funded homecare, as the NAO points out.
Inadequate accountability, evidence and oversight by Government has left the state-funded homecare market at the mercy of under-funded local authorities, acting as monopsony purchasers with no meaningful checks and balances on their activities.
UKHCA has long called for oversight of local authority commissioning of homecare. We believe it should be unlawful for councils and NHS Clinical Commissioning Groups to tender for homecare at fee rates below those which enable full compliance with employment and care regulations, and fair and ethical treatment of the workforce.
UKHCA has consistently advocated for an evidence-based approach to determining costs of homecare delivery and developed the UKHCA Minimum Price for Homecare to assist with this.
According to the NAO, government agrees that costs of care are not being adequately covered by existing council fee rates. It is shameful that they have taken no action to address this.
The government’s recent White Paper “Integration and innovation: working together to improve health and social care for all” lays out aspirations for improving population health outcomes and reducing inequalities.
It states:
“…the case couldn’t be clearer for joining up and integrating care around people rather than around institutional silos – care that focuses not just on treating particular conditions, but also on lifestyles, on healthy behaviours, prevention and helping people live more independent lives for longer”.
UKHCA wholeheartedly agrees that we need to focus on the social determinants of health and on increasing healthy lifespan. We thus endorse NAO’s recommendations for promoting an integrated approach and incentivising commissioning for outcomes. Indeed, we believe the extremes of “time and task commissioning”, such as purchasing homecare by the minute, should be banned.
In order to commission for outcomes, though, we need to agree how to measure them.
The International Consortium for Health Outcome Measurement (ICHOM), which is supported by NHS England, has already developed a range of standard outcome sets, including one relevant for older people. This could be considered for use in adult social care.
Fewer people are receiving state-funded homecare now than in 2015, despite needs rising, placing often intolerable pressure on unpaid carers. Shockingly, government appears to have little idea of the impact of this on individuals, communities and public services more widely and has not sought to find out. We support the collection of data to address these and other key knowledge gaps.
Evidence presented indicates that government lacks up-to-date financial information for three quarters of the care market. Contrary to the narrative in some quarters, NAO data show that levels of profitability of state-funded homecare providers are low (less than zero to five per cent margins are the norm), and 34 per cent of for-profit homecare providers have current liabilities which exceed their current assets. For years, UKHCA has highlighted the lack of financial resilience of the state-funded homecare sector, caused by inadequate fee rates which do not cover provider costs.
Ever since care services were first out-sourced over 30 years ago, local authorities have sought to drive down purchase prices for homecare. The largely female care workforce and the older and disabled people they support have suffered the most from this approach, exacerbating the inequalities laid bare by COVID-19. On top of this, records show that numerous providers have been forced to cease state-funded provision or exit altogether.
It is hard to see how this type of “market shaping” is socially just, or improves public health or the economy, and we need urgent reform.
We all want to live well at home and flourish in our communities.
UKHCA calls on the government to pivot its policies away from institutional care and invest in home-based support for older and disabled people, which 9 out of 10 say they would prefer.
Community-focused integrated social and health care services, underpinned by technology solutions, offer a cost-effective means to increase well-being and healthy life expectancy. In turn, this will support economic recovery and growth. Such an approach will benefit all of us – people using services and their families; people working in care services; the NHS; the wider economy and our communities in every part of the country.
This blog was produced when the Homecare Association was known as UKHCA.
