As we pass the third anniversary of the start of the pandemic, its far-reaching effects continue to be felt keenly by those who draw on social care services and who deliver them. Covid-19 shone a light on the underlying flaws within the social care system and highlighted what needs to be fixed if a more resilient social care system is to be created. But memories are fading and there is a risk that crucial learning will be lost that means social care will remain ill prepared to withstand another crisis in the future.
By talking to people involved in social care – providers, service users, carers, councils and others – about their experiences in the spring of 2020 and by analysing guidance, policy documents and literature, we have examined the key factors that shaped the initial Covid response in social care. We gathered up examples of where things improved between those initial weeks and the spring of 2021 and point to where work is still to be done. Today we publish our report on what we found and what needs to be done to address some serious failings in the system.
Why was the initial response to Covid for social care ‘slow and inconsistent’?
Much has been written about the initial response to Covid in the social care sector. Analysis has highlighted a stark contrast between the ‘whatever it needs’ rhetoric for the NHS and the rather sluggish and piecemeal response in social care. Inconsistent access to PPE and testing in the social care sector dominated conversations during the first wave in 2020. Providers spoke out about how guidance was insufficiently tailored for social care and how emergency funding was uncertain and sporadic. Social care staff reported feeling unsupported, and unpaid carers and people with learning disabilities said they felt forgotten.
As infection rates ebbed and flowed, the national and local response developed and improved – PPE was provided free to social care providers, a social care taskforce was established in the summer of 2020, and unpaid carers were prioritised in the vaccination rollout to name a few examples. But those early months of the pandemic exposed an array of weaknesses within social care that impacted the shape, speed and effectiveness of the response. By shining a light not just on what happened but also why, there is an opportunity to address underlying fault lines and to put the system on a more resilient footing to weather future shocks.
1. Social care was too invisible, complicated and ill prepared for Covid
Covid hit at a point in social care’s history when its flaws had been widely acknowledged by a broad array of stakeholders, from those in high office to care organisations and staff on the front line. Over-promising and under-delivering on social care had been a feature of governments of all hues in the preceding two decades, and multiple plans and proposals over the years had resulted in little tangible improvement. Social care had not been a high priority within central government for some time, and decisions about its future had been kicked repeatedly into the long grass by successive administrations.
This lack of historic priority and investment rendered social care largely invisible in the early weeks of the Covid response. With no specific director general for social care and only modest capacity within the team, interviewees told us that the DHSC was ill prepared for an operational challenge of this magnitude. When crucial decisions were being made about the response, there was no specific voice with an understanding of the complexity of social care and therefore an ability to advocate for it. This relative invisibility was likely a factor in the speed of response – an action plan for social care was not published until 15 April 2020, which was a full month after national lockdown was announced.
A failure to prepare for such a shock was perhaps another consequence of this systemic neglect. While it should be acknowledged that Covid was a novel virus and predicting its impact was difficult, over the years beforehand there were a number of missed opportunities to better prepare social care for a crisis.
Several key pandemic preparedness exercises conducted between 2016 and 2021 pointed to shortcomings in the government and arm’s-length bodies’ response for social care and called for a number of issues to be addressed, but little action was taken in response. As infections were taking hold in Asia and southern Europe in early 2020, lessons from their health sectors were identified and acted upon (leading to the commissioning of more ventilators in the NHS, for instance), but there was less evidence that a concerted and coordinated effort was made to learn from the devastating stories emerging from Spain and Italy’s care homes.
2. The response demonstrated a limited grasp about the diversity and complexity of people who draw on social care
An understanding of the diversity and complexity of the sector was not evident during much of the early response. Many providers of care, people who draw on care and support and their carers were left unsure where to turn for advice. Blanket guidance, about infection control for instance, was frequently written with clinical settings in mind by people with limited operational knowledge of care.
Care organisations, the majority of which are small or medium-sized businesses with limited back-office support, found the frequent updates overwhelming and difficult to interpret, which led to confusion and delays in implementation. Some groups of people – particularly unpaid carers and people with learning disabilities – reported feeling forgotten, as none of the guidance seemed to apply to their situations. This left them unsure on how to protect themselves and the people they cared for.
Confusion over who was responsible within the system for different parts of the response caused further confusion. Although social care is frequently described as “a sector”, this is a shorthand that disguises a mass of enormously complex accountabilities and relationships. In ‘ordinary’ times, that complexity can be an inconvenience to understand and a headache to navigate, but during the early stages of the pandemic it became a serious obstacle to organising and coordinating the response. Stakeholders we spoke to pointed to this confusion as playing a part in the slow speed and coordination of the response, from purchase and distribution of PPE to care staff testing.
3. The state and structure of the social care workforce going into the pandemic was poorly understood within the response, with serious unintended consequences
Social care is one of the biggest employers in England, with a workforce of over 1.6 million. Despite its size and importance, it had been beset by recruitment and retention issues for many years prior to the pandemic. Vacancies, driven by myriad factors including low pay, uncompetitive terms and conditions and a lack of training and development opportunities, topped 100,000 when Covid struck. This meant that an already stretched workforce was suddenly at the forefront of the crisis, and was expected to do more and different tasks while also being at the front line of infection control.
Underlying structural factors, around pay and terms and conditions, were insufficiently considered when infection control policies were put in place. One key oversight was the fact that a large proportion of staff in the sector, employed on zero-hours contracts, had inconsistent access to occupational sick pay. This became a significant issue when policy required anyone with symptoms to isolate for a minimum number of days. As such, many care staff were required to isolate and lose their pay. In the early months of the pandemic, social care staff did not have priority access to testing, so they were required to simply follow the same isolation rules as the general public, creating serious staffing level problems for many employers.
A further oversight was the fact that many care staff work in multiple locations and across numerous providers, on which they rely to earn a living. Policies that restricted staff movement in order to control infection risked paralysing the sector. While that policy was eventually changed in the spring of 2021, its introduction suggested a lack of understanding of the dynamics within this workforce among those leading the response.
4. Long-standing under-investment left a threadbare infrastructure
Emergency funding was made available until March 2022 and was crucial in sustaining social care, particularly during the early stages of Covid as providers were hit by rising costs from PPE, staff sickness and lower occupancy (in residential care). But the years preceding the pandemic were marked not just by funding cuts but also by a trend towards short-term sporadic injections of money instead of multi-year settlements. This financial short-termism had reduced the potential for investment in the essential infrastructure that would have supported the Covid response.
Outdated buildings in residential care – many of which are small, converted houses with few en-suite facilities – were common in the sector. As a result (and further compounded by staff shortages), care homes struggled to follow guidance that required infected or symptomatic residents to be isolated or grouped together. This became an issue of great significance when the decision to rapidly discharge people from hospital into care homes without testing was enacted. There was controversy over the extent to which the action seeded infections in care homes, but that issue aside, it is not clear that the threadbare infrastructure in residential care featured highly enough in decision-making.
Similarly, a lack of investment in data and information over the years meant that there was an absence of information that local and national government could rely on about who draws on care and who provides it. An absence of established channels of communication between DHSC and individual care organisations led to delays and confusion in coordinating parts of the response, such as in PPE distribution and testing. The social care provider landscape is complex with multiple representative bodies for different overlapping segments, which meant that there wasn’t a single portal through which central government could communicate.
Looking forward: building resilience
Covid-19 sent a big shock wave through the social care sector. Our observations focused mainly on the early months of the pandemic, and much learning has taken place since. There has been positive progress, for instance, towards bolstering social care capacity and expertise at DHSC and it is critical that this new capacity is retained and developed. The appointment not only of a specific director general, but also a chief social care nurse, also signalled it as an area of greater priority. Concerted efforts are also being made to build a better data infrastructure through the publication of a new data strategy to support the smooth running of the system in normal times as well as in crisis.
But, while progress is welcome, there is still much to be done. Memories of what happened during the earlier stages of the pandemic are already fading, and valuable learning and momentum for change risk being lost. We have already witnessed the commitment to social care charging reform being delayed and a reduction in the funding committed to workforce reform in the government’s Next Steps document. With each delay, the risk of a loss of visibility and prominence of social care in political and public debate grows.
Most of the problems highlighted in this work were well-known before Covid, but the pandemic has made them more apparent and has demonstrated the consequences of relying on fragile foundations. A persistent short-termist approach to both funding and the workforce, despite repeated urgent calls for action, were significant policy failures of the preceding decades – and were mistakes that left social care so vulnerable at such a time of crisis.
What can be said with certainty is that Covid will not be the last shock that hits the social care system. Whether another pandemic or a different crisis, it is essential that any learning from Covid is harnessed and positive progress built on. There is much to be done to reform this essential service but unless the fundamental building blocks can be set on solid ground, long-term resilience will remain elusive.
This article draws on some of the findings from the ‘Covid-19 and Social Care Recovery and Resilience’ study funded by the National Institute for Health and Care Research (NIHR), Policy Research Programme (PRP) – Recovery, Renewal, Reset: Research to inform policy responses to COVID-19 in the health and social care systems. Reference number: NIHR202333. The article is not based solely on findings from this research. The views expressed in this report are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.