A key question for the future public inquiry into the UK government’s handling of covid-19 will be how well policymakers protected people using and providing adult social care. 

A rehearsal of some of the main arguments is currently being played out in the Health and Social Care and Science and Technology Committee’s inquiry into the covid-19 response so far. Dominic Cummings, the prime minister’s ex-advisor, gave a scathing assessment of the protection given to care homes at the start of the pandemic in his evidence last month. [1] The health and social care secretary, Matt Hancock, will be appearing at the same committee today to offer his own interpretation.

The impact of the pandemic on social care in England has been grim. By April 2021, there had been 27,200 excess deaths—additional deaths compared to recent years—among care home residents, and 9,600 excess deaths among people receiving care at home. [2] Social care staff have been more likely to die from covid-19 than others of the same age and sex. [3] The broader health impacts of the pandemic—from ongoing social isolation, reduced access to care, and the increased burden on unpaid carers—are harder to measure, but also significant.

England is not the only country that has struggled to protect people using and providing care. In almost all countries reporting covid-19 deaths, a large share has been among care home residents. [4] People using social care typically face higher risks from covid-19 because of their age and health conditions. [5,6] And controlling infectious diseases in communal settings, like care homes, is difficult. [7] The ability to protect social care from covid-19 is also tied to the success of wider policies to control covid-19 across the population. The effects of covid-19 on care homes has been closely linked to the prevalence of covid-19 in the community. [4,8,9,10]

But the scale of the impact of covid-19 on social care in England was not inevitable. In May 2020, the health secretary claimed that the government had “tried to throw a protective ring” around care homes since the start of the pandemic. [11] The reality—unfortunately—looked very different. A public inquiry may help us understand who knew what, when, at the heart of government, and how this shaped decision-making. (Is Cummings right that number 10 was misled about covid-19 testing for people in care homes?) But major policy failures on social care are already well known. We don’t need a public inquiry to identify and learn from them. 

Our recent analyses of national policy on social care during covid-19, tell the basic story. [2,12]

During the first wave,central government support for social care in England was too slow and inadequate. [12] The government’s covid-19 social care “action plan” was not published until 15 April 2020—almost a month after countrywide social distancing measures had been introduced. Another month passed before government introduced a dedicated fund to support infection control in care homes. Access to testing and personal protective equipment (PPE) was limited, leading to a lack of protection for people using and providing social care. Care home residents also appear to have been disproportionately affected by reductions in hospital treatment. [13] Overall, protecting adult social care services was given far lower priority than protecting the NHS.

After the first wave, support in some areas improved, such as access to testing and PPE, and the priority given to social care appeared to increase—albeit from a low base. [2] Some kind of national plan for social care was put in place ahead of winter (including an offer of free PPE for the sector), informed by an expert taskforce. [14] Groups using and providing social care were prioritised for covid-19 vaccines, offering much greater protection against the virus. 

But significant issues remained. Policy was fragmented and short-term. And support in key areas, such as on regular testing in social care, still came slowly—including over the summer of 2020, when covid-19 outbreaks continued to occur in care homes, despite very low prevalence of covid-19 in the community. Regular testing policy may have also been too infrequent to prevent care home outbreaks. [15] Some major policy gaps have also persisted—including limited support for the social care workforce and unpaid carers. Government policy has also risked leaving out people using and providing care in some settings, including younger adults with learning disabilities and autism. These gaps may exacerbate inequalities.

Policy decisions taken during the pandemic matter. But underlying structural issues have also shaped the policy response and effects of covid-19 on care users and staff. The social care system that entered the pandemic was a threadbare safety-net, scarred by decades of policy and political neglect. Spending per person fell by 12% in real terms between 2010/11 and 2018/19. [16] Workforce vacancies are estimated at 112,000. [17] And wider staffing issues are chronic: pay is low, staff turnover is high, and a quarter of care workers are on zero hours contracts. [17] The organization of social care in England is also complex and fragmented. 

These issues made the social care system particularly vulnerable to covid-19. For example, 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. [18,19] Longstanding underinvestment meant the system was lacking capacity and resources to respond to a shock like covid-19. Weak central oversight and gaps in data made it harder to coordinate policy.

The public inquiry on covid-19 is not due to start until 2022. But we already know enough about what went wrong in social care to identify lessons for the future. A raft of measures would help: a national workforce strategy for social care, including policy and investment to improve staff pay and conditions; a long-term funding settlement that supports local areas to improve and expand services; a stronger voice for local government in planning and decision-making—the list goes on. Fundamental reform of the funding of social care is also needed to provide greater state protection for people and their families against care costs. But will it happen? 

The prime minister says so. [20] But we’ve been here before. Reform has been promised then ducked by successive governments, and this one—so far—is no different. Covid-19 doesn’t seem to have changed things much: the November 2020 spending review, March 2021 budget, and Queen’s Speech this year all passed without any meaningful plan or money for reform. Continued inaction would be predictable but devastating—and would mean government choosing to prolong the major policy failures so clearly exposed by covid-19.

Hugh Alderwick, Head of policy, Health Foundation.

Competing interests: none declared. 

References:

1. Health and Social Care Committee and Science and Technology Committee. Oral evidence: Coronavirus: Lessons learnt, HC 95. 2021. https://committees.parliament.uk/oralevidence/2249/html/
2. Dunn P, Allen L, Alarilla A, Grimm F, Humphries R, Alderwick H. Adult social care and COVID-19 after the first wave. Health Foundation. 2021. https://www.health.org.uk/publications/reports/adult-social-care-and-covid-19-after-the-first-wave
3. Office for National Statistics. Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered between 9 March and 28 December 2020. ONS. 2021 https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/
causesofdeath/bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/
deathsregisteredbetween9marchand28december2020
4. Comas-Herrera A, Zalakaín J, Lemmon E, Henderson D, Litwin C, Hsu AT, et al. Mortality associated with COVID-19 in care homes: international evidence, data up to 26th January 2021. International Long Term Care Policy Network. 2021. https://ltccovid.org/2021/02/02/updated-international-report-mortality-associated-withcovid-19-in-care-homes-data-up-to-26th-january-2021/
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6. Gordon AL, Goodman C, Achterberg W, et al. Commentary: COVID in care homes: challenges and dilemmas in healthcare delivery. Age and Ageing. 2020; 49(5), 701-705.
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8. Knock ES, Whittles LK, Lees JA, Perez Guzman P, Verity R, Fitzjohn R, et al. Report 41: The 2020 SARS-CoV-2 epidemic in England: key epidemiological drivers and impact of interventions. Imperial College London. 2020. https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-41-rtm/
9. European Centre for Disease Prevention and Control. Increase in fatal cases of COVID-19 among long-term care facility residents in the EU/EEA and the UK. ECDC. 2020. https://www.ecdc.europa.eu/sites/default/files/
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10. Reilly J, Crawford D, O’Boyle D. Coronavirus (COVID-19): care home outbreaks – root cause analysis. Scottish Government. 2020. https://www.gov.scot/publications/root-cause-analysis-care-home-outbreaks/
11. ITV News. Matt Hancock leads the government’s daily coronavirus briefing 15 May ITV News; 15 May 2020. https://www.youtube.com/watch?v=feIQqzk8FPw
12. Dunn P, Allen L, Humphries R, Alderwick H. Adult social care and COVID-19: Assessing the policy response in England so far. Health Foundation. 2020. https://www.health.org.uk/publications/reports/adult-social-care-and-covid-19-assessing-the-policy-response-in-england
13. Grimm F, Hodgson K, Brine R, Deeny SR. Hospital admissions from care homes in England during the COVID-19 pandemic: a retrospective, cross-sectional analysis using linked administrative data. Preprints [preprint]. 2021. doi:10.20944/preprints202102.0593.v1
14. Department of Health and Social Care. Adult social care: our COVID-19 winter plan 2020 to 2021. Gov.uk. 2020. https://www.gov.uk/government/publications/adult-social-care-coronavirus-covid-19-winter-plan-2020-to-2021/adult-social-care-our-covid-19-winter-plan-2020-to-2021
15. 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.org/10.1101/2021.05.17.21257315
16. Health Foundation. The Health Foundation’s response to the Health and Social Care Select Committee inquiry on social care: funding and workforce. Health Foundation. 2020. https://www.health.org.uk/sites/default/files/2020-06/Health-Foundation-submission-to-HSC-social-care-funding-and-workforce-inquiry.pdf
17. Skills for Care. The state of the adult social care sector and workforce in England. 2020. https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx
18. Shallcross L, Burke D, Abbott S, et al. Factors associated with SARS-CoV-2 infection and outbreaks in long-term care facilities in England: a national cross-sectional survey. The Lancet Healthy Longevity. 2021; 2(3): e129-e142.
19. Ladhani SN, Chow JY, Janarthanan R, et al. Increased risk of SARS-CoV-2 infection in staff working across different care homes: enhanced CoVID-19 outbreak investigations in London care Homes. The Journal of Infection. 2020; 81(4): 621-624.
20. House of Commons Liaison Committee. Oral evidence: Evidence from the Prime Minister, HC 1285. Wednesday 24 March 2021. House of Commons. 2021. https://committees.parliament.uk/oralevidence/1995/default/