Performance Tracker 2022/23: Spring update - Adult social care

Covid has hit adult social care services hard. In 2020/21, some 39,000 people in residential and nursing homes died from the virus, ¹⁹⁹ Care Quality Commission, ‘Publication of statistics on deaths involving COVID-19 in care homes in England:
transparency statement’, 12 May 2022, retrieved 28 September 2022, www.cqc.org.uk/publications/majorreports/publication-statistics-deaths-involving-covid-19-care-homes-england discouraging older people from coming forward for care. ²⁰⁰ Bottery S, How Covid-19 has magnified some of social care’s key problems, The King’s Fund, 25 August 2020,
retrieved 28 September 2022, www.kingsfund.org.uk/publications/covid-19-magnified-social-care-problems By the end of 2020/21, both the number of people in long-term nursing and residential care and the number of requests for this care had declined. Some of that demand has now come back, with a year-on-year increase in both the number of people requesting care and the number of people awaiting assessment for care.

At the same time, the workforce crisis that briefly eased during the first year of the pandemic is now worse than ever, with 50,000 fewer posts in the social care workforce filled in March 2022 than at the same point the year before, ²⁰¹ Skills for Care, The size and structure of the adult social care workforce in England, July 2022, retrieved 24
January 2023, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/publications/national-information/The-size-and-structure-of-the-adul… and the highest vacancy rate on record. This has severe implications for providers’ ability to operate effectively. Many directors of adult social services report providers going out of business or handing contracts back, unable to provide enough care to meet demand. This has ripple effects across public services, particularly hospitals and general practice. 

The cost of care is also rising, with providers facing a range of inflationary pressures. In response, the government announced a substantial uplift in funding in the November 2022 autumn statement. A portion of that funding, however, came at the expense of implementation of reforms to adult social care charging. This not only breaks one of the Conservative Party’s key manifesto promises, ²⁰² Conservative Party, The Conservative and Unionist Party Manifesto 2019, retrieved 4 January 2023, p.12,
www.conservatives.com/our-plan/conservative-party-manifesto-2019 but also leaves unresolved a policy issue that dates back at least 25 years ²⁰³ The King’s Fund, ‘A short history of social care funding reform in England: 1997 to 2021’, 28 October 2021,
retrieved 4 January 2023, https://www.kingsfund.org.uk/audio-video/short-history-social-care-funding and means that one in seven people still face ‘catastrophic’ care costs of over £100,000. ²⁰⁴ Tallack C, ‘Does the cap fit?’, Health Foundation, 8 February 2022, retrieved 4 January 2023, p.3, https://ifs.org.uk/sites/default/files/2022-08/Analysing-government-proposed-amendment-English-social-care-chargingsystem.pdf The government has also provided two tranches of additional funding to speed up discharge of patients from hospitals to social care settings.

Covid-related spending on adult social care totalled £5.3bn over the first two years of the pandemic

Local authority Covid-related spending on adult social care amounted to £5.3 billion over 2020/21 and 2021/22, with spending falling from £3.2bn in 2020/21 to £2.2bn in 2021/22. Spending on workforce pressures was the only category to increase over the same period, rising from £231.6 million to £282m, an increase that reflects worsening workforce retention in the second year of the pandemic, discussed further below. This money was spent on a range of initiatives such as supporting payments to increase hours worked, local recruitment initiatives and the hiring of local authority social services staff. ²¹³ Department of Health and Social Care, ‘Workforce Recruitment and Retention Fund for adult social care’, 27
April 2022, retrieved 16 September 2022, www.gov.uk/government/publications/workforce-recruitment-andretention-fund-for-adult-social-care/workforce-recruitment-and-retention-fund-for-adult-s…  

Spending on ‘supporting the market’ – money to prevent providers going out of business – made up the largest proportion of spending in both years, at 39.5% and 39% respectively. The Care Quality Commission (CQC) found that this funding largely achieved its intended purpose, with fewer-than-expected providers closing or handing contracts back. ²¹⁴ Care Quality Commission, ‘Adult social care fragility’, 12 May 2022, retrieved 28 September 2022, www.cqc.org.uk/publications/major-reports/soc202021_02g_asc-fragility But it also found that some providers benefited more than others from emergency funding, with home care providers in particular seeing “stable or improved profit margins over the course of 2020/21”. ²¹⁵ Care Quality Commission, ‘Adult social care fragility’, 12 May 2022, retrieved 28 September 2022, www.cqc.org.uk/publications/major-reports/soc202021_02g_asc-fragility The end of this funding in March 2022 raises questions about market sustainability, as discussed below. 

Grants from central government mostly funded the additional spending. This money was provided as a mixture of un-ringfenced grants that could be spent at the discretion of local authorities and grants intended for specific purposes. ²¹⁶ Brien P, ‘Covid-19: search funding for local authorities in England’, House of Commons Library, 2 February
2022, retrieved 28 September 2022, https://commonslibrary.parliament.uk/covid-19-search-funding-forlocal-authorities-in-england For adult social care, the latter category included grants such as the adult social care Infection Control Fund (worth £2.1bn over 2020/21 and 2021/22 ²¹⁷ Department of Health and Social Care, ‘Adult Social Care Infection Control Fund – round 2: guidance’, 1 July
2022, retrieved 15 July 2022, www.gov.uk/government/publications/adult-social-care-infection-controlfund-round-2/adult-social-care-infection-control-fund-round-2-guidance ^{, 218} Department for Levelling Up, Housing and Communities, ‘Coronavirus (COVID-19): emergency funding for local
government in 2020 to 2021 and additional support in 2021 to 2022’, 30 March 2020, retrieved 12 May 2022,
www.gov.uk/government/publications/covid-19-emergency-funding-for-local-government ), the Workforce Capacity Fund for adult social care (£120m) in 2020/21 ²¹⁹ Department of Health and Social Care, ‘Workforce Capacity Fund for adult social care’, 3 November 2021,
retrieved 22 August 2022, www.gov.uk/government/publications/workforce-capacity-fund-for-adult-socialcare/workforce-capacity-fund-for-adult-social-care and the Workforce Recruitment and Retention Fund for adult social care (£462m) in 2021/22. ²²⁰ Department for Levelling Up, Housing and Communities, ‘Coronavirus (COVID-19): emergency funding for local
government in 2020 to 2021 and additional support in 2021 to 2022’, 30 March 2020, retrieved
12 May 2022, www.gov.uk/government/publications/covid-19-emergency-funding-for-local-government

Central government support drove spending increases during the pandemic

The amount the government spent on adult social care increased by 7.4% in real terms between 2019/20 and 2021/22 (and by 9.6% between 2009/10 and 2021/22). The majority of this increase came from additional local authority spending on adult social care, financed mostly by central government grants that were designed to support both social care users and providers during the pandemic. ²³⁰ Local Government Association and Association of Directors of Adult Social Services, ‘Temporary funding
for adult social care providers during the Covid-19 crisis’, (no date), https://local.gov.uk/sites/default/files/documents/Provider%20fees%20-%20summary%20of%20the%20approach%20proposed%20by%20local%20%20government%20-%20… This additional spending amounted to £3.2bn of the £20.7bn spent on adult social care in 2020/21 and £2.2bn of the £21.4bn spent in 2021/22. This means that across the first two years of the pandemic 12.8% of spending was on emergency Covid measures. 

Excluding the amount spent on Covid, it would appear that spending on adult social care would have fallen during the first two years of the pandemic. This is, however, not quite the case. It is likely that some spending would have been incurred in the absence of Covid, but which was classified as Covid spending because of difficulties distinguishing between ‘business as usual’ and Covid expenditure. It is also likely that some activity that would have continued in the absence of Covid could not go ahead due to the pandemic. This is potentially observable in the lower number of people in long-term care, as discussed below. 

Throughout the winter of 2022/23, adult social care has been the focus of much media and policy attention. However, this has largely been related to the role that the service plays in preventing discharge of patients from hospital – an area identified as a key contributor to the ongoing crisis in secondary care (see the ‘Hospitals’ chapter of this report for more detail). To that end, the government announced £500m of funding to improve discharge from hospitals as part of the Adult Social Care Discharge Fund in September 2022, ²³¹ Department of Health and Social Care, ‘Adult social care discharge fund’, 18 November 2022, www.gov.uk/government/publications/adult-social-care-discharge-fund and a further £200m in January 2023 to “buy thousands of extra beds in care homes and other settings to help discharge more patients who are fit to leave hospitals”. ²³² Department of Health and Social Care, ‘Up to £250 million to speed up hospital discharge’, press release,
9 January 2023, www.gov.uk/government/news/up-to-250-million-to-speed-up-hospital-discharge

This funding will no doubt be welcomed by local authorities, the NHS, and financially stretched providers, but it is problematic for a number of reasons. First, this funding is unlikely to have the desired effect of rapidly increasing social care provision, and in turn freeing up space in hospitals. Much of the money has taken longer than expected to reach providers, with the government only disbursing the first tranche of the Adult Social Care Discharge Fund in December 2022 – three months after it was announced. ²³³ Department of Health and Social Care, ‘Letter to the health and social care sector from the minister for care’,
5 January 2023, www.gov.uk/government/publications/adult-social-care-discharge-fund/letter-to-thehealth-and-social-care-sector-from-the-minister-for-care--2 Once it has been disbursed, it will then take time to reach providers, partly because of high reporting requirements imposed by the government. ²³⁴ Humphries R, ‘Hospital discharge funding: why the frosty reception to new money?’, blog, The Health
Foundation, 13 January 2023, retrieved 24 January 2023, www.health.org.uk/news-and-comment/blogs/hospital-discharge-funding-why-the-frosty-reception-to-new-money Providers then cannot simply tap into a reservoir of ready provision, but instead have to attempt to recruit new staff, invest in capacity, and work with local authorities and the NHS to actually place people in care. Second, and relatedly, this sort of short-term, emergency funding makes it difficult for providers to plan and invest over a longer time period. Third, government will likely pay more than if it had increased funding more predictably and over a longer period of time. ²³⁵ Charles Tallack, Tweet, January 10 2023, https://twitter.com/CharlesTTHF/status/1612807695031046146 Fourth, people might be placed in care that is inappropriate for their needs as they are rushed out of hospitals. ²³⁶ Humphries R, ‘Hospital discharge funding: why the frosty reception to new money?’, blog, The Health
Foundation, 13 January 2023, retrieved 24 January 2023, www.health.org.uk/news-and-comment/blogs/hospital-discharge-funding-why-the-frosty-reception-to-new-money  

In the absence of any further intervention from the government, spending might have fallen back towards pre-pandemic levels in 2023/24 and beyond. But it looks like the trend of increasing spending on the service will continue, as the government used the autumn statement in November 2022 to increase funding for adult social care in 2023/24 and 2024/25. It did this through a mixture of new grant funding, increasing the amount that local authorities could raise each year through council tax, and reallocating the funding that had been earmarked for charging reform by delaying implementation until October 2025 at the earliest. ²³⁷ HM Treasury, Autumn statement, 17 November 2022, p.26–27, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1118417/CCS1022065440-001_SECURE_HMT_Autumn_Statement… Importantly, the government is providing more funding to the least deprived councils, helping to redress the disproportionate cuts they suffered in the 2010s. ²³⁸ Hoddinott S, ‘The government is right to rebalance funding towards disadvantaged councils’, blog, Institute
for Government, 22 December 2022, retrieved 4 January 2023, www.instituteforgovernment.org.uk/blog/government-right-rebalance-funding

In total, the autumn statement provided local authorities with an additional £2.8bn in 2023/24 and £4.7bn in 2024/25. This would represent a 13% and 21.5% uplift in real terms compared to spending on the service in 2019/20. It should be noted, though, that this includes £0.5bn and £1.1bn in 2023/24 and 2024/25 respectively coming from council tax rises. These amounts represent the total that authorities could raise if 95% of authorities exercised their full precepts in both years. It is not, however, clear that all authorities will do so. Raising council tax means asking residents to pay more, something councils may be reluctant to do during a cost of living crisis. As a comparison, only 45% of authorities used their full precept in 2021/22. ²⁴⁸ Kenyon M, ‘Council tax rise makes up £550m of the extra £2.8bn social care funding’, Local Government
Chronicle, 18 November 2022, retrieved 4 January 2023, www.lgcplus.com/services/health-and-care/counciltax-rise-makes-up-550m-of-the-extra-2-8bn-social-care-funding-18-11-2022 According to reports only approximately seven in ten authorities have decided to exercise the full precept in 2023/24. ²⁴⁹ Kenyon M, ‘Revealed: Seven in ten councils to raise council tax by the maximum’, Local Government Chronicle,
13 February 2023, www.lgcplus.com/finance/revealed-seven-in-ten-councils-to-raise-council-tax-by-themaximum-13-02-2023 Nonetheless, this is a substantial uplift in spending on the service. 

Additional funding will help meet rising costs

The additional funding could hardly be more timely as the sector faces a range of cost pressures. While Covid is not as burdensome as during the first two years of the pandemic, there is still a need for increased infection prevention and control, although it is difficult to estimate how much this costs providers. ²⁵⁰ Institute for Government interview ^{, 251} Omar I and Rocks S, ‘What will it cost to get the NHS and social care on the road to recovery?’, The Health
Foundation, 2 September 2021, retrieved 28 September 2022, www.health.org.uk/news-and-comment/blogs/what-will-it-cost-to-get-the-nhs-and-social-care-on-the-road-to-recovery  

The national living wage (NLW) rose 6.6% in April 2022 and will rise a further 9.7% in April 2023. ²⁵² Low Pay Commission, ‘Minimum wage rates for 2023’, 17 November 2022, www.gov.uk/government/publications/minimum-wage-rates-for-2023 Other, non-NLW, wages will also need to rise to improve the recruitment and retention of staff in a tight labour market. ²⁵³ Institute for Government interviews Aside from wages, providers and local authorities now need to spend more to meet rising inflation and costs, such as fuel – be that for travelling between clients ²⁵⁴ Homecare Association, ‘Fuel costs and homecare – impact on service capacity’, Homecare Association, 13 April
2022, retrieved 10 May 2022, www.homecareassociation.org.uk/resource/fuel-costs-and-homecare-impact-on-service-capacity.html or for heating care homes – and food. ²⁵⁵ Association of Directors of Adult Social Services, ADASS Spring Budget Survey 2022, 19 July 2022, p. 19,
www.adass.org.uk/media/9390/adass-spring-budget-survey-2022-pdf-final-no-embargo.pdf ^{, 256} De Albuquerque Green CE, ‘Exploring the effects of the rise of living costs on small to medium sized care
home providers and care professionals’, NIHR Policy Research Unit in Health and Social Care Workforce
at King’s College London, 30 March 2022, retrieved 28 September 2022, https://blogs.kcl.ac.uk/socialcareworkforce/2022/03/30/living-costs-and-care-home-providers

Before the autumn statement, local authorities also faced the prospect of implementing reforms to social care charging in October of this year. The government decided to delay implementation until at least October 2025, following a campaign by local authorities and representative bodies like the County Council Network, who argued that councils would not be able to effectively implement reforms for a number of reasons. First, they claimed that the current level of funding was insufficient to make the changes. ²⁶³ Department of Health and Social Care, Social Care Charging Reform Impact Assessment, 5 January 2022,
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1044903/adult-social-care-charging-reform-impact-asse… Second, they estimate that authorities would need to hire an additional 4,300 social workers – an increase of approximately a quarter compared to current levels – to carry out 200,000 additional assessments per year arising from the reforms. ²⁶⁴ Newton and County Council Network, Preparing for reform, 26 May 2022, p.6, www.countycouncilsnetwork.org.uk/watch-ccn-launches-major-new-report-on-the-governments-social-care-charging-reforms While it is probably true that the amount of money that central government had earmarked for the reforms was not enough, it is questionable whether delaying the reforms until the next parliament was the most appropriate response. The cap on personal care costs would have protected some of the most vulnerable people from catastrophic care costs and meant a fairer means test for others attempting to access the service. ²⁶⁵ Bottery S, ‘Reform of adult social care: some progress, but nowhere near enough’, The King’s Fund, 10 May
2022, retrieved 4 January 2023, www.kingsfund.org.uk/blog/2022/05/reform-adult-social-care-someprogress-nowhere-near-enough Delaying these reforms means that recommendations that the Dilnot commission first made in 2011 may not be implemented until 2025 at the earliest. ²⁶⁶ Commission on Funding of Care and Support, ‘Our report’, 4 July 2011, retrieved 4 January 2023, https://webarchive.nationalarchives.gov.uk/ukgwa/20130221121534/http://www.dilnotcommission.dh.gov.uk/ourreport  

It is yet to be seen what this additional funding will mean for providers. Before the autumn statement, providers were feeling the dual effects of increasing cost pressures and reduced support from central government (among other factors): 64% of councils reported that providers in their area had closed, ceased trading, or handed back contracts in the four months to November 2022. ²⁶⁷ Association of Directors of Adult Social Services, ADASS Autumn Survey Report 2022, 15 November 2022, p. 12,
https://mcusercontent.com/83b2aa68490f97e9418043993/files/0c1fb681-8955-aab3-9c2f-f9a3979ea32c/ADASS_Autumn_Survey_Report_Publication_15_November_202… This compared to 67% in the six months to March 2022, and 25% in the six months to March 2020. ²⁶⁸ Association of Directors of Adult Social Services, ADASS Spring Budget Survey 2022, 19 July 2022, p. 21,
www.adass.org.uk/media/9369/adass-spring-budget-survey-2022-pdf-final-no-embargo.pdf Local authorities are likely to use much of the additional funding from central government to support the social care market. 

Care worker vacancies fell during the first year of the pandemic, but are now on the rise

During the first year of the pandemic, both the turnover rate and the vacancy rate among social care workers fell, following patterns seen across other public services. But this trend reversed from April 2021 onwards, ²⁷³ Skills for Care, ‘Vacancy information – monthly tracking’, (no date), retrieved 1 August 2022, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/COVID-19/Vacancyinformation-monthly-tracking.aspx with the annual vacancy rate reaching 10.7% in 2021/22 ²⁷⁴ Skills for Care, ‘Vacancy information – monthly tracking’, (no date), retrieved 1 August 2022, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/COVID-19/Vacancyinformation-monthly-tracking.aspx – the highest level it has been since the beginning of the Skills for Care time series in 2012/13. There is little sign of this trend reversing; Skills for Care reports that the vacancy rate was 10.8% in December 2022, the most recent month that it has reported. ²⁷⁵ Skills for Care, ‘Vacancy information – monthly tracking’, (no date), retrieved 4 January 2022, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/COVID-19/Vacancy-information-monthly-tracking.as…  

There were 50,000 fewer filled posts in the social care workforce in March 2022 compared with March 2021 

The rise in the vacancy rate was the result of people leaving the adult social care workforce. The number of filled posts in the social care workforce decreased by 50,000 between March 2021 and March 2022, from 1.67 million to 1.62 million. ²⁷⁶ Skills for Care, ‘The size and structure of the adult social care workforce in England’, July 2022, retrieved
1 August 2022, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/publications/national-information/The-size-and-structure-of-the-adul… This included 35,000 fewer carers.* This reduction of the workforce has severe implications for the functioning of the service. Having fewer carers restricts the supply of social care, which in turn makes it harder to place people in care.

A range of factors is driving the exodus of the adult social care workforce. First, care workers were under immense pressure during the first two years of the pandemic and many suffered burnout due to “chronic stress”, ³⁰³ House of Commons Health and Social Care Committee, Workforce Burnout and Resilience in the NHS and Social
Care: Second report of session 2021–22 (HC 22), The Stationery Office, 8 June 2021, retrieved 28 September
2022, p. 11, https://committees.parliament.uk/publications/6158/documents/68766/default causing them to leave for less-intense jobs. Second, approximately 7% of the adult social care workforce comes from the EU, ³⁰⁴ Skills for Care, ‘The size and structure of the adult social care workforce in England’, July 2022, retrieved
1 August 2022, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care… but Brexit has made it harder for EU citizens to work in the UK. ³⁰⁵ Beech J, Bottery S, Charlesworth A and others, Closing the Gap: Key areas for action on the health and care
workforce, The Health Foundation, The King’s Fund and Nuffield Trust, 21 March 2019, p. 117, www.nuffieldtrust.org.uk/files/2019-03/heaj6708-workforce-full-report-web.pdf Third, social care offers few opportunities for training or progression ³⁰⁶ The Health Foundation, The King’s Fund and Nuffield Trust, ‘The value of investing in social care’, October 2021,
www.kingsfund.org.uk/sites/default/files/2021-10/value-investing-social-care-briefing.pdf – factors which encourage people to stay in the sector ³⁰⁷ Institute for Government interview – in comparison with other careers. Fourth, the government mandated vaccination against Covid for all care home workers from November 2021. ³⁰⁸ Department of Health and Social Care, ‘Coronavirus (COVID-19) vaccination of people working or deployed
in care homes: operational guidance’, 1 March 2022, retrieved 5 May 2022, www.gov.uk/government/publications/vaccination-of-people-working-or-deployed-in-care-homes-operational-guidance/coronaviruscovid-19-vaccination-of-pe… Unwillingness to be vaccinated was the second most cited reason among care home staff for leaving the workforce in December 2021. ³⁰⁹ Department of Health and Social Care, ‘Adult social care workforce survey: December 2021 report’,
17 December 2021, retrieved 5 May 2022, www.gov.uk/government/statistics/adult-social-care-workforcesurvey-december-2021/adult-social-care-workforce-survey-december-2021-report Finally, carers are paid poorly compared with workers in other sectors. For example, in 2020/21, the median sales and retail assistant earned 14p more per hour on average than the median care worker. ³¹⁰ Skills for Care, ‘The state of the adult social care sector and workforce in England 2022’, October 2022, p. 15,
www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/State-ofthe-adult-social-care-sector/The-state-of-the-adul… Median pay for care workers in the independent sector fell in real terms between March 2021 to March 2022, from £9.65 per hour to £9.50 per hour. ³¹¹ Skills for Care, ‘The state of the adult social care sector and workforce in England 2022’, October 2022, p. 106,
www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/State-ofthe-adult-social-care-sector/The-state-of-the-adul… Adult social care also competes for workers with the NHS, ³¹² Institute for Government interview which often pays health care assistants and porters more than care workers. ³¹³ Migration Advisory Committee, Adult Social Care and Immigration: A report from the Migration Advisory
Committee, CP 665, The Stationery Office, April 2022, p. 9, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1071678/E02726219_CP_665_Adult_Social_Care_Report_Web… The cost of living crisis is likely to be exacerbating this issue. Nine in ten councils report an increase in the number of people leaving the social care workforce due to the rising cost of working in the sector. In particular, they cite higher fuel costs deterring workers from remaining in the home care sector. ³¹⁴ Association of Directors of Adult Social Services, ADASS Autumn Survey Report 2022, 15 November 2022, p.8,
https://mcusercontent.com/83b2aa68490f97e9418043993/files/0c1fb681-8955-aab3-9c2f-f9a3979ea32c/ADASS_Autumn_Survey_Report_Publication_15_November_202…  

The government has recognised at least some of the difficulties in the adult social care workforce and has taken steps to try to improve the situation. It has added care workers, care assistants and home care workers to the shortage occupation list (SOL) ³¹⁵ Department of Health and Social Care, ‘Biggest visa boost for social care as Health and Care Visa scheme
expanded’, press release, 24 December 2021, https://www.gov.uk/government/news/biggest-visa-boost-for-social-care-as-health-and-care-visa-scheme-expanded – a measure designed to make it easier to recruit in-demand workers from outside the UK. ³¹⁶ Migration Advisory Committee, ‘A guide to the Shortage Occupation List (SOL). Companion to the 2020 SOL
call for evidence’, 27 May 2020, p.2, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/887656/SOL_CfE_guide1.pdf Skills for Care estimates that following the addition to the SOL, the proportion of new starters in the social care workforce arriving from outside the country increased from 4% in 2021 to 11% in 2022, though this could partly be because the number of new starters has fallen compared to 2021. The government also introduced the Workforce Development Fund during the pandemic to promote continuing professional development for care staff. ³¹⁷ Skills for Care, ‘Workforce development fund’, (no date), retrieved 9 January 2023, www.skillsforcare.org.uk/Funding/Workforce-Development-Fund/Workforce-Development-Fund.aspx This was extended into 2022/23, with £500m of funding behind it. ³¹⁸ Department of Health and Social Care, ‘Social care staff to benefit from improved career options and training’,
press release, 10 August 2022, www.gov.uk/government/news/social-care-staff-to-benefit-from-improvedcareer-options-and-training

This workforce crisis comes in the wake of repeated calls for the government to design and implement a long-term workforce strategy. ³¹⁹ Comptroller and Auditor General, The Adult Social Care Workforce in England, Session 2017–2019, HC 714,
National Audit Office, 2018, p. 44, www.nao.org.uk/wp-content/uploads/2018/02/The-adult-social-careworkforce-in-England.pdf ^{, 320} Foster D, Adult Social Care Workforce in England, House of Commons Library, 5 September 2022, p. 30,
https://researchbriefings.files.parliament.uk/documents/CBP-9615/CBP-9615.pdf ^{, 321} Hemmings N, ‘The adult social care workforce: next in the secretary of state’s in-tray or last on the agenda?’,
blog, Nuffield Trust, 18 October 2021, retrieved 28 September 2022, www.nuffieldtrust.org.uk/news-item/theadult-social-care-workforce-next-in-the-secretary-of-state-s-in-tray-or-last-on-the-agenda The Department of Health and Social Care committed to producing a workforce strategy in 2018, after recommendations from the National Audit Office ³²² Comptroller and Auditor General, The Adult Social Care Workforce in England, Session 2017–2019, HC 714,
National Audit Office, 2018, p. 44, www.nao.org.uk/wp-content/uploads/2018/02/The-adult-social-careworkforce-in-England.pdf and the House of Commons Committee of Public Accounts, ³²³ House of Commons Committee of Public Accounts, The Adult Social Care Workforce in England: Thirty-eighth
report of session 2017-19 (HC 690), The Stationery Office, 30 April 2018, https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/690/690.pdf but failed to do so. ³²⁴ Comptroller and Auditor General, The Adult Social Care Market in England, Session 2019–2021, HC 1244,
National Audit Office, 2021, p. 10, www.nao.org.uk/wp-content/uploads/2021/03/The-adult-social-caremarket-in-England.pdf This means there has been no update to the workforce strategy since 2009. ³²⁵ Comptroller and Auditor General, The Adult Social Care Market in England, Session 2019–2021, HC 1244,
National Audit Office, 2021, p. 10, www.nao.org.uk/wp-content/uploads/2021/03/The-adult-social-caremarket-in-England.pdf During the legislative process for the Health and Care Act 2022, the government rejected an amendment that would have required it to commit to regular forecasts. ³²⁶ Health and Care Bill (HL Bill 71, 2021–22), The Stationery Office, 2022, p. 2, https://publications.parliament.uk/pa/bills/cbill/58-02/0301/210301v2.pdf ^{, 327} Murray R, ‘The Health and Care Act 2022: the challenges and opportunities that lie ahead’, blog, The King’s
Fund, 3 May 2022, retrieved 28 September 2022, www.kingsfund.org.uk/blog/2022/05/health-and-care-act-2022-challenges-and-opportunities The government announced in the autumn statement that it would publish a workforce plan for NHS in 2023, ³²⁸ HM Treasury, Autumn statement, 17 November 2022, p.55, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1118417/CCS1022065440-001_SECURE_HMT_Autumn_Statement… but declined to carry out the same exercise for adult social care.

^{* By carer we mean care workers and senior care workers, but do not include personal assistants, who are hired by people given personal budgets to pay for their own care.}

After falling during the first year of the pandemic, requests for care increased in 2021/22

After a decline in requests for care among the 65-plus population in 2020/21, numbers returned to pre-pandemic levels, with 1.37 million requests in both 2019/20 and 2021/22. It might have been expected that the fall in requests in 2020/21 would have created pent-up demand and led to a larger increase in 2021/22. But it is worth remembering that the pandemic continued in 2021/22 and many of the factors that kept people away from care in 2020/21 – the risk of contracting Covid from a carer ³³³ Office for National Statistics, ‘Coronavirus and the impact on caring’, 9 July 2020, retrieved 14 June 2022,
www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/morepeoplehavebeenhelpingothersoutsidetheirhouseholdth… or in a care setting ³³⁴ Morcianao M, Stokes J, Kontopantelis E, Hall E and Turner AJ, ‘Excess mortality for care home residents during
the first 23 weeks of the COVID-19 pandemic in England: a national cohort study’, BMC Medicine, 2021, vol. 19,
no. 71, retrieved 28 September 2022, https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-021-01945-2 and potentially increasing amounts of unpaid care ³³⁵ Carers Week, Carers Week 2020 Research Report: The rise in the number of unpaid carers during the coronavirus
(COVID-19) outbreak, 8 June 2020, p. 4, www.carersuk.org/images/CarersWeek2020/CW_2020_Research_Report_WEB.pdf – are likely to have held true in the second year of the pandemic, thus depressing demand for local authority-provided care. 

In contrast, the number of working-age adults (aged 18–64) requesting care increased in 2021/22, to 611,505 from 577,765 in 2020/21 – a 5.8% rise. From our interviews, it is unclear what drove this increase, but adult social care directors are increasingly concerned about the financial pressure that rising demand for social care from working-age adults will have on spending, due to this group often having more complex and longer-term requirements than the older population (aged 65-plus). ³³⁶ Association of Directors of Adult Social Services, ADASS Spring Survey 2021, 14 July 2021, p. 6, www.adass.org.uk/media/8762/adass-spring-survey-report-2021.pdf

The number of people in long-term care declined in the second year of the pandemic

The number of people in long-term care at the end of the year fell for at least the 12th year in a row in 2021/22, from 616,180 in 2020/21 to 613,510, a 0.4% decline. This fall was not evenly split by care setting. The number of people in community-based care decreased by 1.5%, while the number of people in nursing and residential care rose by 4.2% and 1.5% respectively. 

High Covid mortality in nursing and residential homes had the dual effect of reducing the number of people in care and in all likelihood discouraging people from seeking care in those settings in 2020/21. In 2021/22 there was a slight increase in the number of people receiving long-term care in nursing and residential settings – 175,675 compared to 171,855 in 2020/21 – but this amount is still lower than we might expect, given pent-up demand that could have built up while people stayed away during 2020/21. Despite this increase, the number of people receiving care in residential and nursing settings is also still below where it might have been if the pandemic had not hit. The annual decline in people cared for in those settings was 1.7% per year on average between 2009/10 and 2019/20, while the number declined 3.8% per year on average between 2019/20 and 2021/22. This shift away from these settings is due to a combination of government policy – which aims to increase the number of people cared for at home ³³⁹ Homes and Communities Agency and Ministry of Housing, Communities and Local Government, ‘2010 to
2015 government policy: housing for older and vulnerable people’, 8 May 2015, retrieved 14 June 2022,
www.gov.uk/government/publications/2010-to-2015-government-policy-housing-for-older-and-vulnerablepeople/2010-to-2015-government-policy-housing-for-o… – and an increase in personal preference for home care among older people. ³⁴⁰ Just Group, Social Care: Coronavirus – can the catastrophe be a catalyst?, 2 June 2020, p. 11, www.justgroupplc.co.uk/~/media/Files/J/JRMS-IR/news-doc/2020/just-care-report-final.pdf

The proportion of people in long-term care continued to fall during the pandemic

The proportion of the population aged 65-plus in local authority-funded long-term care fell in 2021/22, from 5,271 people per 100,000 population to 5,054 – a 4.1% year-on-year fall and a 20.1% decrease since 2014/15.

There are a number of explanations for this longer-term shift. First, today, people aged over 65 generally have less need for social care than people of the same age 15 years ago. ³⁴⁹ Raymond A, Bazeer N, Barclay C, Tallack C and Kelly E, ‘Our ageing population: how ageing affects health
and care need in England’, The Health Foundation, December 2021, retrieved 28 September 2022, p. 6,
https://health.org.uk/publications/our-ageing-population Second, cuts in central government grants since 2009/10 have forced local authorities to make tough decisions ³⁵⁰ Atkins G and Hoddinott S, Neighbourhood Services Under Strain: How a decade of cuts and rising demand for
social care affected local services, Institute for Government, April 2022, www.instituteforgovernment.org.uk/publication/neighbourhood-services-under-strain and have resulted in many choosing to ration care, which is easier to do for those aged over 65 than for working-age adults, whose needs tend to be greater. ³⁵¹ Institute for Government interviews Third, because the means test for publicly funded care has been frozen in cash terms, a smaller proportion of people are eligible for it. ³⁵² Bottery S and Jeffries D, ‘Social care 360: access’, The King’s Fund, 1 March 2022, retrieved 28 September 2022,
www.kingsfund.org.uk/publications/social-care-360/access#eligibility Finally, local authorities moved away from being ‘care-package factories’ that offer social care as the first option, ³⁵³ Institute for Government interview to making greater use of ‘asset-based’ models – such as the ‘three conversations’ model ³⁵⁴ Kirin C, ‘How three conversations have changed the way we do social work’, Community Care, 3 May 2016,
retrieved 9 August 2022, www.communitycare.co.uk/2016/05/03/three-conversations-changed-way-socialwork – which aim to integrate people into communities by making use of any skills and connections they have. The aim of this approach is to allow people to live fulfilled, independent lives without relying on long-term social care. ³⁵⁵ Social Care Institute for Excellence, ‘An asset-based approach for communities for better joined-up care’, (no
date), retrieved 9 August 2022, www.scie.org.uk/integrated-care/better-care/guides/work-together/assetbased-approach  

But asset-based approaches may not be fulfilling their purpose, for a couple of reasons. First, it could be that local authorities use these approaches as a means of saving money, in the process pushing caring responsibilities on to families, neighbours and the voluntary sector. ³⁵⁶ Caiels J, Milne A and Beadle-Brown J, ‘Strengths-based approaches in social work and social care: reviewing
the evidence’, Journal of Long-Term Care, 2021, pp. 401–22, https://kar.kent.ac.uk/92788/1/Caiels%20et%20al.%20SBA.pdf Second, there is little evidence about whether these approaches deliver better or worse outcomes.

The number of completed short-term care packages remain below pre-pandemic levels

The number of completed short-term care packages to maximise independence (among both new and existing clients) rose slightly from 246,600 in 2020/21 to 252,145 in 2021/22, a 2.2% increase. This is still, however, below the pre-pandemic amount of 261,605 packages delivered in 2019/20. The reasons for this decline are likely to be similar to those for long-term care packages: people could have avoided care where possible due to Covid. Another reason may be that it was easier at the height of the pandemic to discharge people from hospital into nursing or residential care, rather than into short-term settings, which can require more specialised care. ³⁶⁷ Institute for Government interview There is also evidence of staff shortages during the pandemic leading to reablement staff – who usually assist people coming out of hospital to regain the skills that will allow them to live independently – working in residential homes, therefore making it harder for local authorities to place clients in short-term care. ³⁶⁸ Association of Directors of Adult Social Services, ‘ADASS Winter Contingencies Survey’, 13 January 2022,
retrieved 18 August 2022, www.adass.org.uk/adass-winter-contingencies-survey  

It is also worth noting that if local authorities were pursuing an asset-based approach with the aim of facilitating independent living rather than reducing the amount of budget dedicated to adult social care, then we would expect to see increasing levels of short-term care packages to maximise independence. This outcome is not evident from the data.

There are signs of a backlog in social care demand

The decline in activity in adult social care could mean that there is pent-up demand for care. There is some indication of this already: the Association of Directors of Adult Social Services (ADASS) estimates that as of August 2022, 245,821 people were awaiting assessment for care, ³⁶⁹ Association of Directors of Adult Social Services, ‘ADASS Survey – adult social care: people waiting for
assessments, care or reviews’, 4 August 2022, p. 3, www.adass.org.uk/media/9377/adass-survey-asc-peoplewaiting-for-assessments-care-or-reviews-publication.pdf up from 204,241 in November 2021, ³⁷⁰ Association of Directors of Adult Social Services, Waiting for Care and Support, 13 May 2022, p. 5, www.adass.org.uk/media/9215/adass-survey-waiting-for-care-support-may-2022-final.pdf but down from the peak of 294,449 in April 2022. Among those people waiting, an increasing proportion are waiting longer. Of the 245,821 people awaiting assessment in August 2022, 80,967 of those had been waiting for more than six months. ³⁷¹ Association of Directors of Adult Social Services, ADASS Autumn Survey Report 2022, 15 November 2022, p.16,
https://mcusercontent.com/83b2aa68490f97e9418043993/files/0c1fb681-8955-aab3-9c2f-f9a3979ea32c/ADASS_Autumn_Survey_Report_Publication_15_November_202… At 32.9%, that was the highest proportion since ADASS began collecting this data. Part of the reason for this delay in receiving assessments is that the number of social workers – local authority employees who carry out social care assessments, alongside other responsibilities – declined from 17,500 in 2020 to 17,300 in 2021. ³⁷² Skills for Care, ‘Headline social work information’, September 2021, retrieved 25 May 2022, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/Social-work/Headlinesocial-work-information.aspx While not a large drop (only 1.1%), this does mean that fewer workers are now carrying out a greater volume of work, leading to a bottleneck before people even reach care. 

When a social worker assesses a client as being in need of adult social care, often there is no care available for them, due to the workforce crisis ³⁷³ Hemmings N, ‘The adult social care workforce: next in the secretary of state’s in-tray or last on the agenda?’,
blog, Nuffield Trust, 18 October 2021, retrieved 17 May 2022, www.nuffieldtrust.org.uk/news-item/the-adultsocial-care-workforce-next-in-the-secretary-of-state-s-in-tray-or-last-on-the-agenda and cost pressures described above. ³⁷⁴ Learner S, ‘Care homes turn away residents as staff shortages worsen’, carehome.co.uk, 13 January 2022,
retrieved 17 May 2022, www.carehome.co.uk/news/article.cfm/id/1663313/staff-shortages-care-homesclose This means that people who need care may go without ³⁷⁵ Bird N, ‘Carer shortage: Newport woman left without home visits’, BBC News, 28 September 2021, retrieved
17 May 2022, www.bbc.co.uk/news/uk-wales-58720237 or seek care elsewhere, not least from unpaid carers. ³⁷⁶ Association of Directors of Adult Social Services, ‘ADASS Survey – adult social care: people waiting for
assessments, care or reviews’, 4 August 2022, p. 2, www.adass.org.uk/media/9377/adass-survey-asc-peoplewaiting-for-assessments-care-or-reviews-publication.pdf

The reduction in the number of people in care aged 65 and over, up to 2019/20, despite an increase in the number of requests for care, means it is likely there was substantial unmet demand even before the pandemic. Unmet demand for social care may increase pressures in primary, community and secondary care, ³⁸¹ Hughes L and Keeble M, ‘Investing in social care to reduce healthcare utilisation’, British Journal of General
Practice, 2020, vol. 70, no. 690, pp. 4–5, retrieved 18 May 2022, https://bjgp.org/content/70/690/4 ^{, 382} The Health Foundation, The King’s Fund and Nuffield Trust, ‘The value of investing in social care’, October 2021,
www.kingsfund.org.uk/sites/default/files/2021-10/value-investing-social-care-briefing.pdf although evidence for this is mixed. ³⁸³ Seamer P, Brake S, Moore P, Mohammed MA and Wyatt S, ‘Did government spending cuts to social care for older
people lead to an increase in emergency hospital admissions? An ecological study, England 2005-2016’, BMJ
Open, 2019, vol. 9, no. 4, retrieved 28 September 2022, https://bmjopen.bmj.com/content/9/4/e024577.full It should also be noted that causality between the health and social care systems flows both ways; during the worst of the pandemic, hospitals often discharged patients too early, meaning that they had a higher need for care, putting even more pressure on adult social care. ³⁸⁴ Association of Directors of Adult Social Services, ADASS Spring Budget Survey 2022, 19 July 2022, p. 30,
www.adass.org.uk/media/9390/adass-spring-budget-survey-2022-pdf-final-no-embargo.pdf