Governments across the world are seeking to limit the impact of COVID-19 on health and society. The number of excess deaths – additional deaths compared to the 5-year average – in the UK during the pandemic so far has reached more than 64,000, among the highest in Europe. Daily deaths linked to COVID-19 have been falling since their peak in mid-April, but there is a risk of a future resurgence in cases. The impact of COVID-19 has not been felt equally, with older people, people with underlying health conditions, people living in more deprived areas, and black and minority ethnic groups facing the greatest risks.

The impacts of COVID-19 on people using social care – adults of all ages who need care and support as a result of disability or illness – have been severe. So far there have been more than 30,500 excess deaths among care home residents in England, and 4,500 additional deaths in domiciliary care (care provided in people’s own homes)., There have been examples of services being overwhelmed, leading to failings in care. And there has been a significant increase in deaths among people with learning disabilities and autism. Social care staff – mostly women and more ethnically diverse than the general population – have been around twice as likely to die from COVID-19 as other adults. The amount of unpaid care provided also appears to have increased substantially.,

A complex combination of policies has been introduced in response to COVID-19 in England. The NHS reorganised services, built new hospitals, and increased the supply of staff, beds, and equipment. Government introduced a wide range of social distancing measures – most notably ‘lockdown’ – and passed emergency legislation to help implement these. And economic policy measures have been used to support individuals and businesses during the COVID-19 response, including a large-scale job retention scheme and government-backed loans.

Policies have also been introduced to support the adult social care system during the crisis, including additional funding, changes to legislation, and policies on testing and infection prevention and control. These changes have been developed at different speeds, and interact with policies in other areas, such as the NHS. The Health Secretary, Matt Hancock, claimed that the government has ‘tried to throw a protective ring’ around care homes since the start of the pandemic. But local councils report that social care users and staff have not been adequately protected, and that government funding is not enough to meet people’s needs.

In this briefing, we analyse government policies on social care in England during the COVID-19 outbreak so far – covering the period from the first known COVID-19 case in England (on 31 January 2020) to 31 May. We provide a detailed description and timeline of the government’s social care response. We consider the role that social care has played in the overall policy narrative. And we identify the underlying factors within the social care system, such as its structure and funding, that have shaped its ability to respond. Where possible, we use publicly available data to describe how policies have been implemented. We also provide a summary of the latest data on the impact of COVID-19 on social care. In the final part, we make an assessment of the policy response and identify lessons for the future.

We analysed national government policies on adult social care in England related to COVID-19 between 31 January and 31 May 2020. We also include a small number of other policy developments that took place after this period, if we thought this was needed to understand or reflect the policies we reviewed. We focused only on policies introduced by central government – not policies or guidance affecting the social care system from other national agencies outside government, such as the Local Government Association or major social care charities. We did not review the policies of individual local authorities or social care providers, nor did we assess policies introduced by NHS bodies to strengthen joint working with social care. Our analysis therefore only focuses on a limited part of the policy response.

Our analysis is based primarily on publicly available data. Data on adult social care policies includes government press releases, speeches, guidance documents, letters, and other sources. Much of these data are compiled and categorised in our COVID-19 policy tracker. We used this database as a starting point for our analysis, before searching government and other websites for additional information. Data on the implementation of these policies includes government announcements, select committee papers, official statistics, statements from social care leaders and representative bodies, and other sources. There may be other government letters or communication to the social care sector that are not publicly available and that we do not have access to. Data on the impact of COVID-19 on social care users and staff are from publicly available sources, including the ONS and CQC, and original analysis of linked datasets reported in more detail elsewhere. Differences in local context across England mean there has been significant regional variation in implementation of policies and impact, but our analysis focuses on national level data.

The impact of COVID-19 on social care in England has been severe. In this section of the briefing, we summarise data on COVID-19 cases and outbreaks, movement to and from hospital for care home residents, and deaths of social care users and staff. We place deaths in England in an international context – though comparable data between countries are limited. We also identify gaps in data that limit our understanding about the impact on social care.

Cases and outbreaks

By the end of May, 40% of all care homes had reported a COVID-19 outbreak. Outbreaks varied significantly across the country: 51% of care homes in the north-east had reported an outbreak, compared to 28% of care homes in the south-west. Initial results from a survey of over 9,000 care homes for older residents and those with dementia in England, published in July, estimated that over half of the care homes included in the study had reported at least one confirmed COVID-19 case among either staff or residents. Of these care homes, it was estimated that 20% of residents and 7% of staff had tested positive for COVID-19 since the start of the pandemic. Between 2 and 8 May, CQC reported that around a fifth of domiciliary care providers were caring for at least one person with suspected or confirmed COVID-19.

Hospital discharges to care homes

Hospital discharges to care homes dropped, overall, between 17 March and 30 April. But discharges to nursing homes actually increased compared to the historical average.

Access to health care: hospital admissions among care home residents

Admissions to hospital for care home residents decreased substantially as the pandemic unfolded, with 11,800 fewer admissions during March and April compared to previous years. Elective admissions dropped more dramatically than emergency admissions. And admissions from residential care homes decreased more substantially than from nursing homes. There may be several reasons for this reduction in activity, including policy choices to create hospital capacity – for example, national policies in the NHS to cancel planned operations to help free up space for COVID-19 patients – and changes in the way that care is provided. Infection risks in hospitals may have affected clinical decisions. But the data suggest that there may be unmet need for health care among care home residents as a result of COVID-19.

Deaths

Excess deaths are used to count the number of deaths caused by a particular event, such as a pandemic, that would have been unlikely to occur if the event had not happened. Between 23 March and 19 June 2020, there were more than 30,500 excess deaths among care home residents in England (208% of the average deaths seen in 2017–2019). There were more than 17,700 notifications of deaths involving COVID-19 among care home residents.

CQC introduced a new method of identifying deaths involving COVID-19 for providers registered with CQC on 10 April. By 19 June, CQC had been notified of 819 deaths involving COVID-19 in domiciliary care. Between 23 March and 19 June, there were an estimated 4,500 excess deaths among people receiving domiciliary care (225% of the average deaths seen in 2017-2019). The majority of these deaths have not been linked to COVID-19. Several factors may have contributed to the increase in non-COVID-19 linked deaths in care homes and domiciliary care, including unidentified COVID-19, unmet needs, changes to place of death, and changes in reporting.

There have been high numbers of deaths among people with a learning disability and those subject to the Mental Health Act (including people detained in hospital and those in the community who are subject to the Act) during the pandemic so far. There has also been a disproportionate number of deaths among those from black and minority ethnic groups in adult social care. There has also been a grim toll on staff: people working in social care have been around twice as likely to die of COVID-19 than the general population.

Data

New data collection approaches have been established throughout the pandemic, but not all the data is made public and there are still significant gaps. Data on testing and the spread of infection are lacking across all social care settings, but particularly in domiciliary care. And data on the impact of COVID-19 among domiciliary care users and staff remain limited. There are no data to understand the impact of COVID-19 on those receiving unpaid care.

International data on impacts

England is not alone in experiencing challenges protecting social care from the pandemic. Early data suggest that the impact of COVID-19 among residents and staff in care homes has varied widely between countries., There are no good comparable data to help understand the impact of COVID-19 on community-based social care services internationally.

International comparisons of COVID-19 impacts on social care are complex and risk being misleading. The structure and design of social care services differs between countries. And various other contextual factors – funding levels, integration with health care services, workforce gaps, and other structural issues – will have shaped the policy response and impact in different countries. There has also been no common international approach to testing and recording deaths during the pandemic, limiting what we can learn from early comparisons. That said, there has also been wide variation in the policy measures put in place to protect social care services during the initial stages of the pandemic – including in approaches to testing, financial support, and medical care available to care homes. These differences offer policymakers opportunities to learn from each other as the outbreak unfolds.

The impact of COVID-19 on social care has been shaped – in part – by the underlying structure of the social care system. Measures to support care homes and other services have been implemented in the context of a system scarred by decades of political and policy neglect. Five factors in particular have influenced the social care policy response in England.

Funding levels

Social care services in England entered the crisis enfeebled by many years of underfunding. Spending per person on adult social care fell by around 12% in real terms between 2010/11 and 2018/19. Spending reductions affect access, with fewer people eligible for state funded services. Estimates suggest that a significant number of adults go without the social care they need., But cuts in spending also affect the ability of providers to deliver high-quality care. The amount local authorities are able to pay for somebody’s care in a care home is less than what it costs to provide it. The Competition and Markets Authority estimate that care homes are underpaid by around £1bn a year. People paying for their own social care typically pay more than those receiving publicly funded services, cross-subsidising the low fees paid by local authorities.

Some care providers are going bust, others are handing back their contracts, and the provider sector is at risk of collapse. Even before COVID-19, an estimated £2.1bn would have been needed by 2023/24 just to meet demand for care. COVID-19 has created additional cost-pressures that appear not to be being met (see section on funding).

Workforce issues

Social care services are also in the midst of a deep staffing crisis. Workforce shortages before the pandemic were estimated at 122,000. Staff turnover is high, many staff are on low pay, and a quarter are on zero-hours contracts. COVID-19 can exacerbate these issues, as staff may need to self-isolate, and the need to manage residents in isolation creates challenges for pre-pandemic staffing ratios. The reliance of many providers on agency staff also adds to the risk of transmission – in one survey, 30% of care homes said they were dependent on staff working across several sites. Staff working on zero-hours contracts may have been faced with the choice of going to work with COVID-19 symptoms or losing income (see section on workforce policies). Early data suggest that care homes using bank and agency staff – and the minority of care homes that did not offer staff sick pay – have seen higher COVID-19 infection rates among residents.

The social care sector is also reliant on international migration. People with non-British nationality make up around 17% of the adult social care workforce, but COVID-19 has severely restricted international mobility. For some people coming from outside the EU, many social care roles are not eligible for work visas because they are low paid. This – and the fragmented nature of the sector – has made it difficult for government to offer the same support to social care workers from other countries that it has provided to NHS workers.

Workforce issues in social care also affect the people delivering it. There are an estimated 1.5 million people working in adult social care. Most staff working in social care are women, and 21% of roles are carried out by people who identify as black, Asian or from other minority or multiple ethnicity groups. The system’s reliance on unpaid carers also creates additional challenges in coordinating support. The majority of people providing social care are the families of people with care needs. Carers UK estimate that there were around 9 million unpaid carers in the UK before COVID-19 – and that millions more people have now become carers as a result of the pandemic.

System fragmentation and variation

The social care system is complex and fragmented. There is no single, national system like the NHS. Services are provided by around 18,500 organisations working in 39,000 locations across England. These providers deliver services in a wide range of settings – including care homes, supported living, retirement and extra care housing, people’s own homes, and elsewhere in the community – to adults of all ages.

The scale and diversity of the sector has posed practical and logistical challenges in organising effective policy responses – for example, in ensuring that providers have timely access to sufficient PPE and to testing. National procurement arrangements for the NHS have not always reflected the needs of local care providers who have faced the challenge of navigating their way through various organisational layers to access clear advice, guidance, and support – including access to testing and PPE. Giving evidence to the Public Accounts Committee in June, Chris Wormald, Permanent Secretary at the Department of Health and Social Care, said that he did not think that social care services had been left out of the policy response, but that ‘it is clearly more challenging for us to act in the social care sector, given its fragmentation, than in the NHS’.

Quality and access to social care also varies widely by region. Different local authorities make decisions about how much they spend on which services. Care providers face different recruitment challenges depending on local context. And relationships between social care and the NHS vary across the country – based on historic relationships and other factors. As a result, the ability of social care services to respond to COVID-19 will have varied locally too.

Governance and accountability

These issues have been exacerbated by governance and accountability arrangements in social care. Commissioning of publicly funded social care is done locally, by 151 local authorities. National policy responsibility for social care rests with the Department of Health and Social Care. But responsibility for local authority finances and other issues sit with the Ministry of Housing, Communities and Local Government. The result is a complex web of national and local bodies, with far less national oversight and coordination than the NHS.

There are also historic differences in planning, funding, and decision making between the NHS and social care – contributing to persistent challenges in coordinating services. Local authorities have often not been treated as equal partners by NHS leaders. In this context, the overwhelming priority given to preparing the NHS for COVID-19 and the absence of a clear national strategy for social care in the early stages of the pandemic is – unfortunately – unsurprising.

Lack of data

Quality data on what is happening in social care are lacking. Before COVID-19, there was no system for collecting daily data from care providers. This meant that in the early stages of the crisis, it was difficult to establish an accurate and timely picture of deaths in care homes and other settings. The Office for Statistics Regulation has previously concluded that the social care system is ‘very poorly served’ by data, creating challenges for effective policy development and analysis. And the various data that do exist are not produced in a timely and usable way to inform emergency responses. Matt Keeling told the Science and Technology Committee in June that ‘I remember asking at some point, probably late March, what we knew about care homes, and we did not even know how many people were in care homes at that point. We can only generate models from the data available.’

The impact of COVID-19 on adult social care has been severe. The death toll in care homes and domiciliary care is significant, and people working in social care have been at greater risk of dying from COVID-19 than other adults. Many of those who use social care services face higher risks from COVID-19 because of their age, pre-existing health conditions and given that many live close together in residential and nursing home settings. England is not alone here: most countries have experienced challenges in managing and preventing outbreaks in long-term care settings. But could the scale of the crisis in social care have been reduced?

Based on our analysis of the national policy response in England, the Health Secretary’s claim that the government has ‘tried to throw a protective ring’ around care homes since the start of the pandemic does not appear to be grounded in reality. We identify five lessons from our analysis of national government policy on social care in first phase of the pandemic.

1 Policy action was too slow

Government support for social care services was slow to arrive. Several policies targeted social care in March, including emergency funding in the budget and guidance for social care providers. But the government’s COVID-19 social care action plan was not published until 15 April. This was almost a month after country-wide social distancing measures had been introduced, nearly 2 weeks after the NHS had constructed and opened its first Nightingale hospital, and the same week that the number of excess deaths in care homes peaked. Another month was to elapse before the introduction of the infection control fund for social care. Government launched a national social care recruitment campaign on 24 April, with the aim of bolstering the workforce with 20,000 new staff. Yet the recruitment drive to get retired doctors and nurses back into the NHS to support the COVID-19 response had begun on 19 March – and 750,000 volunteers had already been recruited to support the NHS by early April. There has also been a delay between policies being announced and implemented in some key areas. Overall, government support for social care services came too late.

2 The NHS was prioritised

Protecting the NHS has been a consistent government objective throughout the pandemic so far. The NHS was promised ‘whatever it needs, whatever it costs’ to deal with COVID-19. It responded fast with widespread changes to services and block purchasing of private sector capacity. This focus on ensuring sufficient acute hospital capacity made sense – particularly in the early stages of the crisis, when reports were emerging from Italy of hospitals being overwhelmed with COVID-19 cases, and given the NHS entered the crisis with fewer doctors and nurses, and less equipment per capita than most comparable countries. But protecting and strengthening social care services appears to have been given far lower priority by national policymakers – with slow access to PPE and testing, and less certainty for councils about funding. Data about deaths in care settings were not available in the early weeks of the crisis, and social care leaders were absent in daily press briefings until 8 June.

Ultimately, health and social care services interact in a complex system. The overriding priority given to protecting the NHS in the early stages of the pandemic may help to explain why the potential unintended consequences of rapidly discharging patients from hospitals to care homes – without testing for COVID-19 – appear not to have been fully foreseen. Decisions to discharge patients were made by clinical teams in good faith and in an unknown and urgent context. And leaving medically stable care home residents in hospitals would have carried other risks. But the national push to free up space in hospitals may have played a role in transferring risk to a poorly prepared social care system lacking the right protection.

3 Narrow focus on care homes

The adult social care system delivers a wide range of services to adults of all ages. Around 842,000 adults received long-term support from local authorities in England in 2018–19. While debates about social care often focus on older people, 35% of those receiving care are aged 18–64. Social care is delivered in a mix of settings – including care homes, supported living and extra care housing, people’s private homes, and elsewhere in the community.

While there has been a growing focus in the media on deaths in care homes during the pandemic, there has also been a significant increase in deaths among people receiving care in their own homes. National policies on social care during the pandemic so far have focused primarily on care homes – not the wider social care system. Policies on testing are one example of this. A government announcement on 28 April stated that testing would now be expanded to all asymptomatic NHS and social care staff, but the testing expansion in social care only covered staff in care homes. And personal care assistants and unpaid carers were not added to the list of essential workers until the beginning of May. Whole care home testing was initially implemented for care homes for people aged 65 and older. The risk is that government protection and support has not reached all parts of the social care system.

4 Unmet need and unintended consequences

Temporary powers to relax the Care Act and widespread pressures on services are likely to create unmet need and have potential unintended consequences. Even before COVID-19, unmet need for social care among both younger and older adults was high., While data on unmet need are limited, the pandemic appears to have made this worse: almost a quarter of council leaders surveyed by ADASS reported that unmet need for social care in their area could have increased by around 1–5% during the outbreak so far. Data on hospital admissions among care home residents also suggest that there may be unmet need for health care services as a result of the pandemic.

Emergency measures to relax the Care Act have been implemented in a small number of local authorities – meaning that assessments of care needs do not need to take place and, in the most severe cases, councils only need to meet a person’s needs if not doing so will breach their human rights. These decisions to delay or reduce social care for some groups are a product of constrained resources and challenges delivering care safely, but will inevitably store up problems for the future. There may also be unintended consequences of the government’s decision to allow local councils to provide ‘free’ social care services for people during the pandemic but charge for these services retrospectively – including unplanned financial strain on people and families, and reduced trust in services.

5 A backdrop of political neglect

No policy action on social care during COVID-19 could undo the effects of decades of political neglect. As we have outlined, the social care system that entered the pandemic was underfunded, understaffed, undervalued, and at risk of collapse. Cuts in social care have been one part of wider cuts to local government budgets, including for public health. This was no secret: adult social care services in England are widely thought to be inadequate and unsustainable. Publicly funded care is only available to people with the highest needs and lowest means. Despite this, successive governments have avoided fundamental reform of the system.

Any response to COVID-19 – however fast or comprehensive – would have needed to contend with this legacy of political neglect. The failure of successive governments to reform social care is being laid bare. While the Prime Minister has restated the government’s commitment to reforming social care as the country emerges from the first peak of the virus, history tells us that we should see it before we believe it. And the Prime Minister’s framing of ‘the problem’ in social care – the unfairness of some people having to sell their homes to pay for care – suggests a very narrow interpretation of the issues to be addressed.

Policy priorities

At the daily briefing on 3 May, Michael Gove, Minister for the Cabinet Office, said ‘undoubtedly, this government, like all governments, will have made mistakes’. It will be for a future inquiry to make judgements on these mistakes and how they could have been avoided. In the short term, the priority for government must be to identify lessons from the first stage of the pandemic to help prepare for potential future waves of COVID-19. Our analysis of the policy response on social care points to several immediate priorities.

In next phase of the COVID-19 response, national government leaders should:

• Give the same political priority to protecting social care services as hospitals and the NHS.
• Include the social care sector as equal partners in planning and decision making. At a national level, the new social care sector COVID-19 support taskforce offers one route to do this. Greater involvement of social care expertise and experience, including in areas such as learning disabilities and autism, will improve national decision making.
• Ensure that national policies, including those related to the NHS, encourage the meaningful involvement of social care in local planning and decision-making processes – including sustainability and transformation partnerships and integrated care systems.
• Give equal recognition to the value of NHS and social care staff and reflect this in any new support schemes and the policy narrative used to describe them.
• Continue to improve the availability of regular testing and PPE for the social care sector, and ensure access to the training and other support needed to reduce infection risks.
• Commit to providing the necessary funding to cover additional COVID-19 costs incurred by local government and care providers, such as extra staffing and PPE costs.
• Recognise the interdependency of health and social care in COVID-19 policies and guidance. Identify gaps in services that need to be addressed and ensure that care homes can access enhanced support from primary and community health services. This includes the national implementation of the NHS enhanced health care in care homes service.
• Ensure that plans to manage and prevent further outbreaks take into account the diversity of social care services and the varied requirements of staff and users in different settings – including in domiciliary care, other settings outside care homes, and for unpaid carers.
• Work to improve the quality, accuracy, and timeliness of data in adult social care to inform local and national decision making. This should include a minimum dataset for care homes and improved availability of data on other services. Plans to improve social care data should be included in the government’s forthcoming National Data Strategy.

More fundamental reform of the social care system is also needed to address the longstanding policy failures exposed by COVID-19. Priorities for government include:

• Stabilising and sustaining the social care system so that it can better meet people’s needs. This should include policy action and investment to improve staff pay and conditions.
• Increasing access to publicly funded social care services to help address unmet need.
• Reforming the social care funding system to provide greater government protection for individuals against social care costs. One model to do this – a cap on lifetime care costs – already lies on the statute book. This could be used flexibly by government depending on choices about the balance of responsibility between individuals and the state.

Comprehensive reform of the social care system will require additional government investment. But reform is not unaffordable. If it chooses to, government can afford to provide more generous care and support for vulnerable people in society. If it does not, government will be choosing to prolong one of the biggest policy failures of our generation.

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We would like to thank Adam Briggs, Natasha Curry, Gen Cameron, Karen Hodgson, Sarah Deeny, Charles Tallack, Nihar Shembavnekar and Jennifer Dixon for their comments on earlier drafts of the paper. We are also grateful for the contribution of other Health Foundation staff, including Sean Agass and Pete Stilwell. Errors or omissions remain the responsibility of the authors alone.

Contains public sector information licensed under the Open Government Licence v3.0.

When referencing this publication please use the following URL: https://doi.org/10.37829/HF-2020-P06