COVID-19 has continued to take a grim toll on people using and providing social care in England. The proportion of all COVID-19 deaths taking place among care home residents has fallen since the first wave of the pandemic, but there were still 20,423 COVID-19 deaths among care home residents in England between 5 September 2020 and 2 April 2021. Excess deaths have remained high among people receiving care at home. The broader health impacts of the pandemic on people using and providing social care are also likely to be significant, including the effects of ongoing social isolation, reduced access to care, and the increased practical and psychological burden on people providing care. Our analysis provides a detailed picture of the policies introduced by central government to try to reduce these impacts.

Challenges protecting social care are not unique to England. In almost all countries with COVID-19 deaths, a large share has been among care home residents. People using social care typically face higher risk from the virus because of their age and health conditions., Controlling infectious diseases in communal settings, such as care homes, is challenging.

Protecting social care during the pandemic is also tied to the broader task of protecting the population from COVID-19. Evidence suggests that the effects of COVID-19 on care homes have been closely linked to the prevalence of COVID-19 in the community.,,, This means that the wider policy response to COVID-19 – for example, the effectiveness of lockdowns and testing systems – shapes the ability to protect adult social care services and staff. Changes to policy and practice at a local level – by local authorities, health and care systems, and care providers – have also impacted the protection afforded to people in social care. Publicly funded social care is commissioned locally by 151 local authorities, and care is provided by around 18,200 organisations working in 38,000 locations across England. Central government policy is one part of a complex and fragmented adult social care system. Learning from variation in approaches to managing the pandemic locally will be important.

But what national policymakers do to protect and support social care still matters. And the scale of the impact that COVID-19 has had on social care in England was not inevitable. In our previous analysis of social care policies during the first wave of the COVID-19 response, we concluded that the health secretary’s claim that the government had ‘tried to throw a protective ring’ around care homes since the start of the pandemic was not grounded in reality. How far has the policy response changed since then? We identify six lessons from our analysis of national policies on adult social care in England since June 2020.

1 Some improvements in the response

In some areas, policy support for adult social care has improved – partly due to the changing pandemic context and wider improvements in the policy response. In the first wave of the pandemic, protecting and strengthening social care services was given far lower priority by national policymakers than protecting the NHS. Social care received limited attention in the political narrative. And people using and providing social care had slow access to PPE, testing, and other policy support, leaving them without adequate protection from COVID-19.

From this low base, the attention given to social care by national policymakers has increased. The Department of Health and Social Care established an expert taskforce to advise on social care policy ahead of winter 2020/21, led by an experienced social care leader. This led to a national plan for adult social care being put in place at the start of the second wave of COVID-19, including extended funding for infection prevention and control measures in care homes and other settings, and a promise of free PPE for the sector. Policies have been developed to try to improve interactions with the NHS, including expanding health care support for residents in care homes. And groups using and providing social care were prioritised for COVID-19 vaccines, alongside the NHS. The COVID-19 vaccination programme has been a broad success so far, and is likely to have offered much greater protection to care home residents.

Supply of testing and PPE to social care has also improved over time. This is likely to have offered greater protection for people using and providing social care. But a lack of clear publicly available data makes it hard to know how far policies on testing and PPE are meeting the sector’s needs. And some problems with policies in these areas have persisted.

2 Fragmented and short-term policy

Despite improvements since the first wave, government policy on social care has often been fragmented and short term in focus. For example, the government only provided indemnity insurance for social care providers operating as ‘designated settings’ for people with COVID-19 leaving hospital in mid-January 2021 – several months after the scheme was announced ahead of winter. Even then, the insurance offer was temporary until the end of March 2021, before being extended by government a week before it was due to end. More positively, the government’s offer of free PPE for the social care sector has now been extended to March 2022 – albeit after a series of short-term extensions in early 2021.

Funding in several other policy areas, including for infection control measures and testing, was narrowly defined and not easily adaptable to the fast-changing context. Government extended funding in these areas only weeks before reaching a cliff-edge. Piecemeal funding creates uncertainty for the sector and makes it hard to plan for the long term., Care providers have also faced the challenge of keeping up with and interpreting a growing number of frequently updated and potentially confusing official guidance documents.,,

3 Policy action was still slow

Problems with the timing of government policy have also persisted. During the first wave of the pandemic response, government intervention to support and strengthen social care arrived too late. The government’s initial ‘action plan’ for adult social care was not published until 15 April 2020 – almost a month after country-wide social distancing measures had been introduced, and the same week that the number of excess deaths in care homes peaked.

After the first wave, policies in key areas still came slowly. For example, expansions of COVID-19 testing programmes in social care often arrived late and not always in the form originally promised. And regular testing – as with other support – reached some staff groups much later than others. Regular testing in older adult care homes was announced in July 2020, but its implementation was delayed and then only extended to other care homes at the end of August. Despite very low prevalence of COVID-19 in the community between June and August 2020, low numbers of COVID-19 outbreaks continued to occur in care homes in England. The frequency of staff testing may also have been insufficient. Frequent testing of staff – ideally daily – is likely to be critical to preventing outbreaks in care homes.

Support for more vulnerable staff was also slow to arrive. Ethnic minority communities are overrepresented in the social care workforce and are at higher risk from COVID-19. But government action to protect these groups appeared an afterthought. National policy on social care providers carrying out risk assessments to help protect ethnic minority and other staff at higher risk from COVID-19 was not announced until mid-June – long after rates of COVID-19 in social care peaked, and nearly 2 months after assessments for NHS staff were requested. This risks worsening the already unequal impacts of COVID-19.,

4 Gaps in the policy response

Major gaps in the policy response remain. In our previous analysis, we identified a narrow focus on care homes in government policy during the first wave of the pandemic. Prioritising national policy support for care homes is understandable, given the higher risks faced by care home residents, and the challenges controlling infections in communal settings. But social care is delivered in a mix of settings to adults of all ages. While debates about social care often focus on older people, 35% of people receiving care are aged between 18 and 64.

After the first wave, government policy continued to prioritise care homes – particularly those for older adults – and risked leaving out people providing and using care in other settings. The government’s social care winter plan made only seven references to home care, and day services and respite services for unpaid carers received just two mentions. Care homes were mentioned over 100 times. The sector’s regulator has raised concerns about slow and limited access to testing for younger adults with learning disabilities and autism cared for in residential services and their own homes.

National policy support for the social care workforce has also been limited. For example, migrant workers are an essential part of the care workforce in England and make up around 16% of social care jobs. But government policy has not treated these care workers equally to migrant workers in the NHS during the pandemic. In November 2020, government extended its offer of free visa extensions for ‘overseas health and care workers’ to those whose visas were going to expire before 31 March 2021 (later extended again to October), because they ‘truly value the work these heroes are doing’. But most social care workers were not eligible for the extension, as the offer only covered registered professionals. In August 2020, government introduced its new Health and Care Visa to make it ‘cheaper, quicker and easier’ for ‘health and care professionals’ to come from abroad to work in the UK as part of its post-Brexit immigration system. But – again – the vast majority of social care workers are excluded from this policy because they do not have a registered qualification or earn enough. Government support for the millions of unpaid carers has also been limited, despite recommendations from its expert taskforce to strengthen the support on offer to them.

5 Lack of available data limits understanding

A lack of publicly available data means that we only know so much about the impacts of the pandemic on social care, and the success of policies to support the sector. More data have been collected to support policymakers over the course of the pandemic – including through government’s capacity trackers and social care dashboard. Government has recently begun publishing some of these data for care homes for 15 December onwards, but major gaps remain. Data on care provided outside care homes are limited, likely incomplete, and challenging to interpret. Further research is needed to understand the root causes of high excess deaths experienced among people receiving domiciliary care during the pandemic. Data on self-funders, unpaid carers, and unmet need are also lacking.

These issues are nothing new: they reflect longstanding weaknesses in how social care data are collected, used, and shared., Government is expected to publish a national data strategy for health and social care, alongside findings from a review of how health and care data can be used to support research and analysis. The government’s February 2021 white paper on health and care reform also proposed new measures to improve the volume and quality of social care data. To be successful, these policies will need to go beyond what data are collected to consider how they are used to improve care – including the investment needed to boost data infrastructure, data literacy, and the effective use of data analytics.

There is also limited evidence on the implementation and impacts of policies affecting adult social care during the pandemic, including the use of Care Act easements and revised hospital discharge arrangements. Robust evaluations of these complex service changes are needed to improve understanding of what worked in which contexts, and to ensure decisions about how they are adapted are based on evidence, not rhetoric. Engaging patients and the public in this process will be critical to understand whether services are meeting their needs.

6 Major structural challenges remain

Throughout the pandemic, longstanding structural issues in social care have shaped the policy response and effects of COVID-19 on care users and staff. These issues are well known and include chronic underfunding, workforce gaps, poor terms and conditions for staff, high levels of unmet need, overreliance on unpaid carers, system fragmentation, and more. For example, the fragmentation of social care services has created challenges coordinating policy support. And a lack of adequate sick pay for many care workers and a reliance on agency staff appear to have contributed to greater risks of COVID-19 infection in care homes., Political neglect of adult social care in England is a story that – unfortunately – dates back decades not years. The pandemic has laid bare these political failures for all to see.

COVID-19 appears to have made some longstanding problems worse. Unmet need for social care and the burden on unpaid carers are likely to have increased. Care home residents may have faced additional barriers to accessing hospital treatment during the first wave of the pandemic – and many may still be waiting for essential health care. The pandemic will likely have long-run effects on already diminished local government finances., And concern about the sustainability of the social care provider market is widespread and growing.,,

Government action to address these structural issues has not yet materialised. The government’s Spending Review in November 2020 provided local authorities with the bare minimum needed to meet rising demand for care, with no investment to improve quality or expand access to the threadbare state system., The government’s white paper on health and care reform in February 2021 focused on reform to the NHS, with no sign of the Prime Minister’s long-promised plan to fix social care ‘once and for all’. Social care was ignored again by government in its March 2021 budget. No further details on social care reform were provided in the Queen’s speech in May 2021. Government still has no national strategy to develop and support the social care workforce. The list goes on.

Policy priorities

Nonetheless, at the House of Commons Liaison Committee in March 2021, the Prime Minister said that ‘the government will be bringing forward our proposals on social care […] reform later this year’. Fundamental reform is needed to address the longstanding policy failures exposed by COVID-19. Short-term action is also needed to support the social care system to recover from the pandemic and prepare for potential future waves of COVID-19.

Our analysis points to several priorities for government as it develops its plans on social care:

  • Ensure that there is a robust and clear framework of policy and financial support to sustain and protect social care services over the rest of 2021 and into 2022. This should address the potential for further waves of infection, concerns about the fragility of local authorities and care providers, and the need to be prepared for winter.
  • Ensure that national policy during the pandemic and beyond reflects the diverse needs of people using and providing care – including services delivered outside care homes and unpaid carers. Greater policy attention is needed on the differential impacts of the pandemic on staff and service users with disabilities and those from ethnic minority groups.
  • Develop a comprehensive workforce strategy for adult social care, including measures to increase pay and improve terms and conditions for social care workers. Immediate action is also needed to ensure enough staff to provide care and protect staff during the pandemic, including ensuring that no staff lose out on pay while self-isolating.
  • Continue to strengthen the Department of Health and Social Care’s capacity, expertise, and leadership on social care policy so that it can effectively support local authorities and care providers. Increased national oversight of social care must be combined with sufficient resources and support to deliver and improve local services.
  • Improve the quality, accuracy, timeliness, and transparency of data in adult social care to inform national policy and local decision making. The government’s national data strategy and review of the use of health and care data offer opportunities to do this.
  • Identify gaps in services to be addressed for people using or in need of social care. Give the same political priority to restoring social care services affected by the pandemic as to addressing the backlog of unmet need for the NHS.
  • Ensure that the government’s planned reforms to the structure of the NHS in England provide a stronger voice for local government in local planning and decision making. This includes meaningful involvement in newly established integrated care systems.
  • Deliver the government’s commitment to reform adult social care in England and bring forward plans to do so this year. This reform must be comprehensive – not narrowly focused on preventing older people selling their homes to pay for care. In addition to measures to improve staff pay and conditions, this must include action to:
    • stabilise and sustain the current system so that it can better meet people’s needs
    • increase access to publicly funded social care to help address unmet care needs
    • reform the social care funding system to provide greater government protection for individuals against social care costs. Various options are available to do this.

Comprehensive reform of adult social care in England will require additional government investment. But after the devastating impact of the pandemic, the question is surely no longer whether we can afford better social care in our society, but how can we afford not to?

****** For recent modelling (not yet peer reviewed) see Rosello A et al. Impact of non-pharmaceutical interventions on SARS-CoV-2 outbreaks in English care homes: a modelling study. medRxiv [Preprint]. 2021 (doi: doi.org/10.1101/2021.05.17.21257315).

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