Social Care

Baroness Andrews Excerpts

Thursday 30th March 2023 Lords Chamber

Moved by

[Baroness Andrews]

That this House takes note of the future of adult social care given (1) the recent reports from the House of Lords Adult Social Care Committee (HL Paper 99) and the Archbishops’ Commission on Reimagining Care, (2) the Care Quality Commission s local authority assessment duties which commence from 1 April, and (3) His Majesty’s Government’s stated intention to publish a social care plan in Spring 2023.

[Baroness Andrews (Lab)]

My Lords, I am extremely grateful for this opportunity to introduce a debate which has a particular resonance in this House and a real urgency. I am very pleased that so many Members of the House have been able to take part today, particularly members of the Adult Social Care Committee. I am delighted to share the debate with the Church, alongside the right reverend Prelate the Bishop of Carlisle and the most reverend Primate the Archbishop of Canterbury. We are considering two reports, in respect of which Church and state are joined in values and prescriptions. We are also anticipating some of the changes coming down the track. I regret that we do not have the national care plan today, as we had hoped, but we can anticipate the CQC changes. There is a lot to discuss, and the debate will go far wider than the two reports before us.

We have not yet had a reply to our Select Committee report, A “Gloriously Ordinary Life”, which was published last December, but I hope the Minister will be able to say something about the national care plan, not least when it will be published and when we can debate it. Perhaps he could answer one or two of the outstanding questions, such as: will the £500 million workforce funding plan be halved?

I said that this debate has a particular resonance in this House, and there can be very few noble Lords who have not had the experience of caring for someone close to them. It is estimated that one in two of us is likely to become an unpaid carer by the time we reach 50. For some people, it is a lifetime’s commitment; for others, it is an overnight change in circumstances that leaves them with a future which is darker and very different. Overall, at any one time about 10 million adults of all ages come into contact with adult social care. When it matters so much to so many people, we are bound to ask why, as a whole, it has been out of sight and off the public radar for so long. Perhaps a better question is: why do we not care more about it—sufficient to make it the social and political priority it needs to be? What do we need to change in order to care more, and to plan and provide more effectively for a fairer and more robust service? Why is it not a national imperative? The answers to these questions are rooted partly in human frailty and partly in the history of the NHS and the time in which it was born: a time when women did not work and people did not live as long.

What is significant about the two reports is not that they reach similar conclusions, but that they are rooted in similar values which start from the assumption that adult social care has so far been denied the opportunity to be what it could and should be: a service that enables people to live a gloriously ordinary life which is fruitful, active and valuable. The support provided is not transactional or contractual; it is based on a generous and mutually supportive set of relationships which reflect what, at best, being cared for and caring mean. The Archbishops’ Commission’s report, Care and Support Reimagined, describes it as a fulfilled life based on love, mutuality and interdependence, embedded in the concept of a national care covenant.

Today’s realities are very different. Many of those who need care or support in order to care, particularly as unpaid carers, battle their way through a barrage of services, systems, agencies, tests and charging regimes that seem designed to deter demand until needs become extreme. The daily realities are set out in our report in the words of those who live that reality. We were extremely privileged to hear so many witnesses share their experiences and their lives with us—people who have lost jobs, homes and health in the process of caring. That co-production helped our report to reach a wider audience, and we owe them a huge debt of gratitude, as we do our superb committee staff—Megan Jones, Daphné Le Prince-Ringuet, Alasdair Love and Abdullah Ahmad—our wonderful special advisers, Jon Glasby and Anna Severin, herself an expert by experience, and every member of the committee who gave so much time and insight and shared their own experiences. I am sorry that the noble Lord, Lord Laming, could not be in his place today. He kicked this off through the Liaison Committee and helped us settle on a topic in a very well-worked field which has not had the attention it deserves—the plight of the unpaid carer.

Caring goes on day and night, without public acclaim, in private, behind closed doors, and with pitiful reward. Indeed, unpaid carers were described by no less than Jeremy Hunt, when chair of the Health and Social Care Committee, as the least visible aspect of a service which, overall, suffers from “entrenched” invisibility. Understanding what that means for adult social was a task we undertook, and trying to work out how to dismantle it consumed much of our inquiry, because invisibility takes many forms and has many impacts. Adult social care may be a nationally funded service, but it is locally delivered. It does not have a coherent national profile; it is fragmented across 18,000 organisations. While care homes are, tragically, more in the national spotlight because of Covid, the rest of the service is below the radar until you need it—when you cannot find it. At its most graphic, although it is the same size as the health service and of equal importance to the well-being of the nation, its budget is a fraction of the NHS’s: £17 billion compared with £153 billion. As we know—this statistic is all too familiar—a third of local government funding has been lost in the past decade. Compared with the NHS, adult social care is not the national treasure it should be.

This is not a remote failure. At the start of 2022, 2.6 million over 60s were living with some form of unmet need, such as the basics of washing and eating, and 2.2 million hours of care had been lost in the first three months of that year. Half a million people are now waiting for assessment. Care support, as it was described to us, even when it comes with the best of intentions and people, can still make people feel very grudging and guilty rather than supported.

The relative invisibility of the service is compounded by a lack of information. We were astonished by what we did not know. The number of unpaid carers is estimated at between 4.2 million and 6.5 million, but there may be many more who are not registered because of the problem of identification. We know that they save the country £132 billion a year, but less well known is that they receive the lowest of all benefits—£2 an hour, or £69.70 a week. To get that, you have to work for more than 35 hours a week and fulfil a means test. It is no wonder they are worried sick about heating and food bills, and that they do not manage to stay in work—and when they do, the support they get is significantly less than that offered by other countries. Put together with a paid workforce which is not valued for its exceptional skills and which works for less than the minimum wage, it is hardly surprising that they are driven out of a job they love or that it is so hard to find a personal assistant these days.

The reports provide all the evidence any Government would need as to why this is urgent, and they set out a plan for change. Both say unconditionally that there must be a radical shift in perception and investment in all parts of the service, so that adult social care can become the transformational life-enhancing service it could have been designed to be. We heard someone say to us informally, “The NHS saved my life. Adult social care has helped me to live it.” That was a graphic description.

The greatest failure has been the failure to plan strategically for an ageing society. The result is that we see longer life as something to be borne, a burden, a nuisance—and that cannot now just be fixed. That needs to be seen together with the repeated failures to cap residential care; to implement the Care Act 2014; to integrate social care into the health service, until recently; to prepare a realistic adult workforce plan based on skills, a full pay review, and a resilient service that people feel proud to be part of; and to challenge the false economy of underinvestment in adult social care year on year, at a time when the impact on the health service alone is immeasurably worse.

Add to that the failure to honour the promises that have actually been made to unpaid carers: better leave, a better carer’s allowance, better respite. It is a catalogue of disappointment. There has been so much analysis and diagnosis, so much hand-wringing over failure and so little meaningful change.

But the future is catching up with us: we will have a population of about 2 million in 10 years’ time who will be ageing without care, with no family to look after them. Where are the plans for these people to get the support they need? At the same time, if we are smart, we have new technologies and new devices that can help reduce risk and plan for where the skill gaps are. I think of the wonderful Tribe Project we came across, which does outstanding work but which ought to be all across the country. We saw so much good practice in local authorities as different as Wigan and Somerset, and an appetite for innovation and for engagement with the community. There are tremendously creative ideas at local level, all waiting to be galvanised and shared.

The most challenging question of all is what needs to change before we care more sufficiently to make adult social care a national imperative. Four things are necessary: to raise adult social care’s voice, visibility and agency; to revisit and build on what already could work better; to build capacity through workforce skills and strategic investment; and to change the way we view it—as a unique social good in itself, not simply part of propping up the NHS.

First, and simply, adult social care has to have a louder, more coherent and challenging voice, so that it can be more powerfully championed inside and outside government. It has been too easy to get away with simply patching up adult social care in an emergency and parking the workforce strategy. It has not had the power to fight for priority, which is extraordinary when we think of the power it has to change lives, for better or worse.

We recommend what looks like an easy reach, but which could make a huge difference: a commissioner for care and support to lead that fight, to raise that voice, to hold Ministers’ feet to the fire, to do some shaming if necessary, but also to celebrate and mobilise the best. That champion will be a champion for unpaid carers as well, to make sure the Government cannot get away with any more delay and procrastination there.

Reducing invisibility means knowing more: to do better, we have to fill those information gaps. We have to have a national plan for data on adult social care, so that we actually know who is caring when and where; so we know where the gaps are, where the resources can be deployed best, and what we need to invest in most effectively. That could also be helped by creating an R&D network akin to that in the NHS, so that we could trap ideas, innovation and good practice. If we have increased visibility, we can have more and better opportunities to design more flexible services—more “choice and control”, as is described, whether through better access to better packages that work more effectively, more personal assistants with less bureaucracy, direct payments that actually get to where they are needed, or giving respect to enable unpaid carers to give their own expertise more effectively, as full partners in providing care.

I have been banging on about housing in this House for well over a decade. We need accessible and adapted housing, so that we do not have thousands of people stuck in hospitals. They should be able to go to a safe home and be looked after safely, not just at times when care is needed, but urgently, as a matter of sensible planning for an ageing society. The social care White Paper recognises the role of housing, so I very much hope we will see some funding come forward to actually meet that desire.

So much of what is in these reports is not new; so much was set out in the Care Act 2014—principles, processes, project design. It is tragic that it has been on the statute book but not implemented by local authorities, which have not been able to put the training plans in place; they have not been funded to do so. That leads to the inescapable reality that adult social care needs a national investment strategy.

Compared with the costs of failure and delay, adult social care is not expensive. Again, when the Chancellor was chair of the Health and Social Care Select Committee in 2017 he called for an annual increase of £7 billion between 2021 and 2023—this at a time when energy companies are scooping up hundreds of billions. This is the same Chancellor, though, who did not put any additional money for adult social care in the Budget. I ask the Minister what he thought of that.

In conclusion, so much of this is not about money at all; it is about moving away from the culture and perception of a service where the dominant language is not that of celebration but of “burden”, of “dependence”, of “failure” and of “crisis”, towards one which values and empowers the people it serves and those who do the caring, paid and unpaid. Among the assumptions which must change are the long-held assumptions that disabled adults and older people are not capable of living a life that is as rich and fulfilling as everyone else’s; that social care work is unskilled work; and that families will always be there to care.

Let me put it another way and quote Social Care Future:

“We all want to live in a place we call home, with the people and things we love, in communities where we look out for one another, doing what matters to us.”


It seems to be the most modest of ambitions—so many of the things that are asked for are so modest—but one that is well within reach if we choose to do it. The greatest risk, as our report says, is not to change, and the hardest question is, if not now, when? We have waited long enough to make adult social care a national treasure as well as a national imperative. I really hope the Minister agrees with me this afternoon. I beg to move.

--- Later in debate ---

[Baroness Andrews (Lab)]

My Lords, I am very grateful to the Minister for his response, for the compassion he shows and for the shared values we clearly hold across the Chamber. He had a difficult job trying to sum up and satisfy the consensus of opinion and expertise across the House while not being able to tell us what the national plan will contain. We regret that it will be published in the Recess. We would like an immediate opportunity to debate it. I hope that business managers will give us that opportunity as soon as possible when we come back, and that we can have a substantial debate on it, as well as on the Select Committee’s report. In the meantime, I think that everyone would be very grateful to join him and officials around a table, not least because it signals the inclusivity which marks the debate and marks what my noble friend Lord Turnberg called the “noise” that has been associated with the debate for so long. We want to take up that offer.

I thank the noble Lord, Lord Polak, for identifying the need to take politics out of social care, because that is only too evidently what needs to happen. We must be as committed to finding the investment, particularly in the workforce, as we are to making sure that we understand the values we share.

I thank everyone who has taken part; it has been an exceptional debate. I thank noble Lords for their generous response to both reports. It was very good that we had the opportunity to listen to the most reverend Primate and the right reverend Prelate on the notion of a covenant and the very specific overlap in the consensus about what needs to be done—it has been an incredibly valuable opportunity because of that.

There have been very valuable speeches from across the Chamber, including from my noble friend on the Front Bench. It has been a comprehensive debate, but it has been as broad and rich as it has been deep because of the personal experience that it has called up, as well as the range of professional experience and the types of caring that people know about—learning disabilities, elderly care, disabled people. We heard from the trade union perspective the challenge of reconstructing a workforce that is modern and fit for the future. We heard from the unpaid carers’ perspective.

It has been an extraordinarily important debate for the Minister, because the challenges that have been articulated and the detail have been rooted in real experience over many years across this House. This House has a very long memory, having been here before, time and again. This is the time for change. Whatever is in that national care plan will be tested to destruction against our experience of 20 to 30 years of waiting and hoping for something better and bringing it to the boil in different ways. Nothing about this is easy and nothing will be particularly quick, but let us have some clarity, total transparency and reality, but let us also have that vision. The most reverend Primate started by asking who is responsible. That is such a fundamental question, and the answer is that we all are. That is something that has come out in the inclusive nature of this debate as well. With that, I beg to move.

Motion agreed.