Social Care and the Role of Carers

Motion to Take Note

Moved by

That this House takes note of social care provision in the United Kingdom, and the role of carers in that provision.

My Lords, it is a great pleasure to open this debate on social care. I am sure it will be rich and varied, and that the Minister will struggle to sum up the points made in the time he is given. I am sure we will welcome a letter from him with his responses to our more trying queries. This debate also doubles as my health and care swansong, as I now move to defence.

I start by putting on record my, and our, utmost thanks to all those who work in social care systems, from carers to cleaners and caterers, to management in care homes and domiciliary care, and those who provide so much care for friends and family, expecting nothing in return.

I want to cast our minds back to the time of the coalition, when the Liberal Democrats made reform of social care an absolute priority, and the Dilnot commission provided a framework for us to fix the inherent unfairness in how social care is funded and provided. Cross-party talks were promising and it felt as though progress was being made. Not so. Later, both Prime Ministers May and Johnson said that they would sort it. But somewhere along the way this issue has been pushed into the long grass again and again, despite two Conservative Prime Ministers pledging to make it a priority. Of course, Covid has not helped.

So will it be Dilnot, Forsyth or something completely different? How will it be funded? We have seen, over the last year, what is possible when resources and energy are mobilised to address a crisis. We know that this an issue exercising the Chancellor. I want to be clear: what is happening in social care is a crisis, and we need to approach it as such.

Looking at the sector since the onset of Covid, we see that the Government have provided significant short-term support to help care providers through Covid-19, but it is vital that the Department of Health and Social Care now sets out how it will help providers move beyond it. The costs of the pandemic and the dramatic fall in care home occupancy, from around 90% at the start of the pandemic to 80% in February this year, puts many providers at risk of failing. In response, the Government provided short-term funding through local authorities and the infection control fund. This support has stabilised the market and kept most providers from falling over. However, the department does not have a strong grip on the variable levels of support that individual providers received, and there have been some reports of providers struggling to access some of the additional funding. The commitments around extra funding and free PPE—personal protective equipment—until the end of next March are welcome, but the department does not yet have a road map outlining how long extra funding and support will be in place. Can the Minister tell us please?

The Care Quality Commission warns that ongoing support is likely to be required in 2021-22 if care home admissions remain low or costs are inflated. Can the Minister tell the House whether the Department of Health and Social Care, working with the Ministry of Housing, Communities and Local Government, has an assessment process in place to determine how much support providers need in the short to medium term to deal with Covid-19 and lower occupancy in care homes?

My Lords, the forensic, measured and moving opening speech of the noble Baroness, Lady Jolly, demonstrated that there are a number of pressing issues to be addressed within the wide topic of social care. The Government have committed themselves to resolving the issue of who pays for residential care in old age, and we are all eager to learn of their plans as hundreds of families face this challenge every month. I shall focus in my three minutes on two points: social care provided by the not-for-profit sector; and social care provided by family, friends and others who are unpaid—what is called informal care.

As chair of the National Housing Federation—I declare that interest—I have taken a keen interest in housing associations’ provision of not-for-profit care and housing, and seen the amazing work they do not just for the elderly but for those with disabilities, learning difficulties and physical and mental illness. I echo the call from Anchor Hanover, England largest not-for-profit provider, on the need to tackle the negative perceptions of social care in terms of low pay and lack of career progression. This is not new: before the pandemic, there was a shortfall of 1.1 million care workers in the next 15 years. With a current workforce estimate of 1.6 million, that is a massive challenge. What will the Government do to deal urgently with these negative perceptions and begin to address the shortage challenge?

On my second point, about informal carers, my noble friend Lady Pitkeathley has consistently and passionately advocated their cause in this House; I look forward to hearing her contribution shortly. In my experience, the majority of all social care is provided by family or friends caring for their loved ones. In most cases, they do not even label themselves as carers; they do it because they are husbands or wives, daughters or sons, sisters or brothers. It is what they do, and it is what we do. This vast army of carers increased dramatically during the pandemic. In most areas, services for carers, including young carers, vanished overnight, and there are real concerns that they will not be reinstated. There are an estimated 13.6 million of them, plus 800,000 young carers, yet they are often invisible when it comes to public policy and they have to fight every inch of the way for support, often at the cost of their own health or financial security.

I congratulate the noble Baroness, Lady Jolly, on securing this timely debate. I declare my interests with Marie Curie, the Motor Neurone Disease Association and other charities; I also chair the National Mental Capacity Forum.

There are two main groups needing social care: those with long-term chronic conditions, both physical and mental disorders, often both; and those who are terminally ill and dying. The first group often slips into the second as disease progresses. I want to focus on those families providing unpaid informal care. More than three-quarters of those carers bereaved during Covid reported that they were not offered the care and support they needed, and Carers UK data suggests that one in three may be nearing breaking point. Pre pandemic, it was no better. The Motor Neurone Disease Association found that more than 75% of unpaid carers had not had a carer’s assessment and a third spend more than 100 hours a week caring. When caring for other conditions, the average hours are less, but more than 1 million people are providing 50 or more hours of care per week. Marie Curie estimated that there were 6.2 million carers in the UK in 2018 and 500,000 were looking after someone with a terminal illness, which is about 8% of all carers.

Most informal carers are not professionally trained, and of the 1 million people eligible for attendance allowance, it is estimated that about a third do not claim it. When someone is nearing dying, a prognosis of six months is impossible to provide with accuracy, so the DS1500 form for funding is sometimes filled in relatively late, leaving the financial burden on the family even greater. For many, the care of a person who is critically ill, whose recovery is unpredictable or who has been in intensive care is particularly difficult. These family carers need to be taught some basics of caring and they need to know who to call for immediate support 24/7. The current systems of even supporting them are not adequate.

My Lords, I declare my interests as a vice-president of the National Autistic Society, as an ambassador for the Alzheimer’s Society and as an informal carer. I congratulate the noble Baroness, Lady Jolly, on securing this debate. I shall miss her contributions in this area, which we have shared over many years. I am going to leave to others today discussion of the urgent need to reform social care for the elderly and flag up how important it is that reform, when it comes, includes those of working age.

According to Rethink Mental Illness, from 18 to retirement age, those with mental illness, learning disabilities, autism, as well as physical disability and declining mental health, are among a third of adult social care users. Half of the spend of the adult social care budget is with this group, which gives a good idea of the numbers. Services are stretched and, since March 2019, they have been reduced due to Covid. Legislation that we already have on the statute book—the Care Act 2014, the Mental Health Act, the Mental Capacity Act, and the long-awaited strategy to go with the Autism Act 2009—is meant to provide statutory services for all those people. People have a right to expect them to be provided. This House has supported that legislation along with the codes of practice and some of them are not even implemented. I hope that when we see the new reform, there will be a review of everything on the statute book to make sure that it is being used in practice.

Perhaps I may say a word about informal carers. Informal carers of working-age adults struggle. It is estimated that they are over 7% of the population. Parents and carers battle to advocate for adult children when services are not provided. That leads to mental health breakdown of both carers and those cared for. We have yet to learn the lesson of making cuts to low-hanging fruit in this area. It is all too easy to cut out some of the low-budget issues such as advocacy, befriending, welfare rights and employment—to name but a few. They are easy things to remove, but there are big consequences when they are. We are being made to wait and wait for the long-promised social care reform, So, when it is presented, there should be no excuse if it is not comprehensive, fair and fit for purpose. I say to the Minister: bring it on.

I congratulate the noble Baroness, Lady Jolly, on securing this timely debate. I should declare an interest as co-chair of a newly formed archbishops’ commission on reimagining social care. Understandably, much of the current discussion of social care involves the issue of funding. That is fundamentally important, but I believe the time has also come for a radical—in the sense of going to its roots—reappraisal of the values and principles underlying social care, not only for the elderly but for those with disabilities and severe mental illnesses. It has been clear for many years that we need an inspiring, cross-party, long-term vision for social care which involves rethinking how we want it to be understood as well as delivered, with those in need of care valued for who they are rather than simply regarded as an inconvenient burden. It has also been clear that that should include reference to some of the underlying societal conditions that contribute to the overall need, such as deprivation, lack of family support and loneliness.

Within this general framework, I want to focus on two specific areas that have already been raised and must demand our attention. One concerns the status, recruitment and retention of paid carers, especially in care homes. This issue has of course been highlighted by the particular burdens placed on care home staff during the pandemic. Quite often, those staff have had to work in more than one care home, with attendant implications for both their health and well-being and that of residents. It is essential that we raise the status of paid carers to ensure that caring, like service in the NHS, becomes a viable career choice rather than a last resort. Being a carer should be as much a source of pride and dignity as being a healthcare professional. This would involve the registration of carers, a suitable suite of qualifications, agreed national pay scales and realistic career progression structures.

The other specific area is the role of informal unpaid carers, including family members, who enable people, as we have just heard, to stay in their homes and who need better recognition. This applies in particular to the 750,000 or so young carers in England, many of whom, as we have recently been reminded in your Lordships’ House, regularly miss school and have little or no extra support. They, together with unpaid carers of all ages, need to be identified and properly supported if the UK’s standards of social care are to become world class.

My Lords, I shall speak about home carers which is something I know about as I have them myself. So, I declare that interest. I feel strongly that being a carer is not a low-skilled job. Even helping to dress a frail, elderly or disabled person safely is a skill which should be recognised. Disabled people might be under the care of well-paid hospital consultants, but the consultants could not do their job without the day-to-day work of competent but low-paid carers. Half-hour-only visits are common, with no travelling time paid. It is not uncommon for carers to be the first people to find that a client has fallen or even has died in the night. Carers, particularly in large cities, are often from overseas and have to get used to difficult clients who sometimes resort to mild racial abuse, particularly if those clients are slipping into dementia. Good carers are like gold dust. They should be much better rewarded.

We are in a vicious cycle. After decades of reviews and failed reforms, the level of unmet need rises, the pressure on unpaid carers grows, the supply of care providers diminishes and the strain on undervalued care workers ever increases. Yet, far from having an “oven ready” social care deal, the Government are seemingly paralysed and constantly postpone the hard decisions they need to make.

Paid carers make up a 1.5 million workforce, but there are millions more unpaid carers. As a society, we rely on unpaid carers and exploit them while giving them a lack of personal support, respite care or funding. Carers UK has carried out research on the impact of the pandemic on unpaid carers. It shows that 81% of carers provided more care during the pandemic, 64% have not been able to take any break because of a lack of respite care, and 74% feel exhausted and worn out. If we are to support these amazing people, we have to reform social care, starting with implementation of the Dilnot proposals by putting a cap on care costs, but that is not sufficient. As Dilnot himself has said, additionally we need a pay rise for social care staff and extra cash for the current system to increase the numbers eligible for care. It will cost: the Health Foundation says £11 billion a year, but I suspect that is an underestimate. Rather like the experience of the NHS at its formation, there is a huge level of unmet need that will emerge if the current tight eligibility criteria are relaxed, as they must be. It will cost, but if our experience of the last 15 months has taught us anything it is that it is imperative to sort this out.

Why then have the Government postponed a decision time after time? It appears that the latest setback is due to the Prime Minister’s financial illiteracy in refusing to allow any increase in income tax, VAT or national insurance to pay the additional cost. He may think it is smart politics. He may think it is best to waste money on vanity projects such as the ludicrous proposal for a new royal yacht—I wish the noble Baroness, Lady Jolly, much joy in focusing on that and other defence matters in the future—but the Prime Minister’s ultimate legacy will be to be remembered as a man who ducked the most pressing public policy issue of the day.

My Lords, I too congratulate the noble Baroness, Lady Jolly, and echo the thanks for the wonderful work done by carers. Our care system is broken: every part of it is in need of radical change, from the arbitrary distinction between what counts as social care and what qualifies you for NHS healthcare, the healthcare lottery; to the way in which care is provided, the postcode lottery; to the standards applied to the workforce of 1.5 million people, such as social care nurses relative to NHS nurses, an employment lottery; to the lack of funding that has increasingly rationed care; to the draconian means test and funding shortfalls, which force the entire cost of care on to the most vulnerable, who pay not only significant sums for their own care but usually a 20% or 30% surcharge to subsidise council underfunding as well, whereas those who do not need care pay nothing; to the lack of support for unpaid carers; and to the financial fragility of care home operators, who can load their business with debt, extract equity, take rental income to their offshore companies, and have provided handsome profits to hedge funds, which buy and sell their distressed debt.

Each of these parts of the system needs reform, and there is no silver bullet. Extra funding is of course needed, but system redesign is also required. Leaving social care to cash-strapped councils leaves more than 1 million people who need care. The demographics are such that, within the next 10 years, the enormous bulge of baby boomers will start to enter care needs. At the moment, the current cohort is rather small. Social care seems to have been the forgotten front line at the start of the pandemic, and it was used by the NHS as an overflow service, perhaps being considered as part of the private sector rather than part of the health service. If someone has a health problem, however, and they need social care, why should that not qualify for free basic care at the point of need? It could be modelled on the lines of our pension system.