This evidence was presented to the Welsh Assembly Health, Social Care & Sport Committee on the Impact of Coronavirus on 9 December 2020.
General Comment
The Association of Directors of Social Services (ADSS Cymru) is the professional and strategic leadership organisation for social services in Wales and is composed of statutory Directors of Social Services, the Heads of Service and Tier Three managers who support them in delivering statutory responsibilities and accountabilities; a group of more than 100 social services leaders across the 22 local authorities in Wales.
As the national leadership organisation for social services in Wales, the role of ADSS Cymru is to represent the collective, authoritative voice of Directors of Social Services, Heads of Adult and Children’s Services, together with senior professionals who support vulnerable adults and children, their families and communities, on a range of national and regional issues of social care policy, practice and resourcing. It is the only national body that can articulate the view of those professionals who lead our social care services.
As a member-led organisation, ADSS Cymru is committed to using the wealth of its members’ experience and expertise, working in partnership with other agencies, to influence important decisions around social care to the benefit of the people it supports and the people who work within care services.
ADSS Cymru welcomes the opportunity to respond to the Health, Social Care and Sport Committee’s inquiry into the impact of the COVID-19 (COVID) pandemic on health and social care in Wales and how it has been managed over the last nine months.
The pandemic has been an unprecedented challenge for all of Welsh society but none more so than the health and social care sector. Statutory service commissioners and their provider partners have been pushed to their very limits in trying to respond to and deliver services in, what has been an exceptional public health emergency. Our members working within local government have been at the forefront of the current emergency and mid-way through a second wave of the virus, we continue to meet the exceptional challenge of COVID in partnership with Welsh Government, statutory agencies, public sector partners in health, as well as vital third sector organisations and an army of community volunteers. Despite the positive news of vaccines and new rapid testing technologies coming on stream in the near future, COVID is still very much here and with a potential third wave of the virus in the new year, we all must continue to be very cautious in managing the risk.
As highlighted at our recent National Social Care Digital Conference by Cllr Huw David, Cabinet-lead for Social Care on the WLGA, the pandemic has placed a spotlight on the incredibly valuable role social care plays in its own right. Social care staff have been on the frontline throughout this crisis, risking their lives, doing an incredible job in extremely challenging circumstances to protect those they care for. Our members working through their respective councils continue to do all they can to support people receiving care, whether at home or in other settings. Moreover, while much has been learnt about the virus over the past nine months, the number of cases in the community reflect that it is essential that we continue to learn from previous experience and do not make the same mistakes again. The Welsh Government needs to ensure that councils and social care providers have all the support and resources they need for the weeks and months ahead. However, for the medium and longer-term, Welsh Government must look to deliver on the full implementation of A Healthier Wales. Social care deserves parity of esteem with the NHS and this needs to be backed up by a genuine, long-term and sustainable funding settlement for social care, which local government has been calling for, long before the current crisis.
Partnership working during the pandemic ADSS Cymru has underlined its leadership credentials by working closely with Welsh Government and other statutory partner agencies, at the very highest level, from the onset of this emergency, to ensure that locally, regionally and national, the response has been as co-ordinated and joined-up as possible.
Throughout the outbreak, Directors and Heads of Service, have served on and, in a number of instances, led specific, national, multi-agency working groups, to aid the development of emergency legislation; to develop new and updated operational policies, procedures, protocols and guidance and disseminate them to the wider professional social care network; to collate and share data with Government and key strategic partners on a range of key indicators like safeguarding referrals, testing, workforce and care capacity in various settings. Most of this work has taken place at break-neck speed and around the clock, 24/7.
In addition to this work, ADSS Cymru members have also actively collaborated with both the Older People’s Commissioners for Wales and the Children’s Commissioner for Wales, on key priority areas they have focused on during the pandemic and public lockdown, including sitting on the Older People’s Commissioner’s Virtual Abuse Group.
ADSS Cymru has led the way in distributing key communication messages and information from several statutory partners, including Welsh Government, Social Care Wales (SCW), Care Inspectorate Wales (CIW) and the Welsh Local Government Association (WLGA). ADSS Cymru’s communication team collates and circulates a bi-lingual bulletin on a bi-weekly basis (on a weekly basis throughout the initial response stage) to a wide network of health and care professionals in Wales and via CIW, to registered care providers as well.
In many cases responding to the pandemic has strengthened joint working at local, regional and national levels, with more agile and responsive decision making and action planning being enabled. Relationships with providers have been strengthened by the continual dialogue with local authorities and others, supporting them with the provision of advice and updates, as well as shared learning. This mobilised activity and effort of ADSS Cymru members has enhanced and strengthened the offer of support to care providers, such as establishing PPE supply routes, rolling out training and advice from ourselves and other key partners, or helping to redeploying staff and volunteers.
Financial sustainability of commissioned providers
The fragility of the care provider market was well understood by ADSS Cymru members and the Welsh Government, before the pandemic struck. So much so, that through the Delivering Transformation Grant (DTG) programme over the past few years, ADSS Cymru has developed a number of policy and research papers for Government on innovative funding models to meet social care needs,i re-balancing the care market (for both adults and children’s services),ii mapping co-operative provision in domiciliary care in Walesiii and strengthening integrated commissioning with NHS Wales through new technical advice and guidance.iv The financial short comings in relation to cost pressures and cost differentiation that existed before the COVID crisis must be acknowledged and understood in order to put the current period in context.
ADSS Cymru believes that the pandemic has exacerbated the precarious financial position that many care providers have found themselves in and calls into question the long-term viability of a number of care providers in the market, particularly within the residential care market.
While we welcomed the Government’s commitment to support commissioned providers in adult services through vital cash injections during the pandemic (particularly from the Hardship Fund), we still have significant concerns about providers surviving in the short-term, particularly if a third wave emerges towards the start of next year, which could put unprecedented stress on the social care system. ADSS Cymru members continue to monitor this situation closely both locally and regionally, in collaboration with the WLGA and the Society of Local Authority Chief Executives in Wales (SOLACE Wales).
For example, the WLGA has just completed its Local Services Spending Round Survey. This information, coupled with two quarterly reports, is a considerable body of data demonstrating the pressures being faced by the sector. Demand led services in the social care sector have been particularly badly affected and real concern about service continuity and the on-going impact on finances is evident in councils’ responses. The responses also highlight the key role played by council commissioned private care providers many of whom are small and lack the financial resilience of larger providers. Therefore, it is right to highlight the important role local authorities played financially in the early weeks and months of the pandemic to ensure that there was no critical collapse within the independent care provider market. Authorities went at risk and provided financial support before any funding criteria was agreed with Welsh Government. Moreover, local authorities have also provided their own staff to independent providers at their own cost to keep them viable during times of staff shortages.
ADSS Cymru is acutely aware of the anxieties that some care providers (particularly residential care providers) have about being able to survive in the short term, particularly in relation to additional cost pressures for PPE, insurance liabilities, staffing and the pressure of carrying COVID-related vacancies and what impact this will have on their cash flow and ability to operate. That is why we quickly co-produced and published a piece of critical guidance at the end of March with four of our principle statutory partners – the Welsh Government, the Welsh Local Government Association (WLGA), Care Inspectorate Wales (CIW) and Social Care Wales – to enable Local Authority commissioners to support their care providers. The COVID-19: Support for Commissioned Providers guidance1 is designed to summarise a range of pressures on social care providers in Wales arising from COVID and to put forward practical ways in which commissioners can alleviate these pressures. For example, there are several suggestions in the guidance to assist providers alleviate some of their cash-flow pressures by encouraging commissioners to:
- Increase the frequency and speed of payments, making payments in advance of delivery, making rapid repayment the norm;
- Review arrangements for invoice reconciliation in order to ensure expedited payments;
- Ensure that disputed amounts do not delay payment of regular invoice amounts;
- Increase the discretion of providers to deliver more / less care to individuals based on staff supply and priority needs;
- Pay providers for planned care when citizens refuse visits without notice.
While the guidance has been a well-received and well utilised tool, the risk remains that without some additional support some care homes could go into financial collapse. Failures in the sector could see homes being returned to the public sector, but it comes at a time when local authorities and other providers have limited or no capacity to intervene. This means that capacity would be lost from the sector. Moreover, it would also have a significant impact on the ability to support the hospital discharge process (Discharge to Recover and Assess – D2RA), which will result in an even greater pressure being placed on domiciliary care.
It is imperative that Welsh Government continue to work closely with ADSS Cymru to develop sufficient packages of financial support in the short and medium term, to enable providers to survive this current period of challenge and uncertainty. Additional funding to local authorities for their commissioned providers should be made available with as few a set of conditions as possible to allow local flexibility to address local circumstances.
Adult services
Unsurprisingly, Adult Social Care has featured as a key concern for our members during the pandemic, particularly balancing the continued need to deliver the Social Services and Wellbeing (Wales) Act with the on-going COVID pressures, which is currently being funded through Welsh Government’s Hardship Fund. This has been a significant financial support mechanism but currently only covers the 2020-21 financial year. Demographic pressure means that costs are rising at a time when there is increasing concern about market fragility. The WLGA have highlighted that claim data coming from the hardship fund shows the monthly claims of between £8m and £12m are needed for the sector. This will amount to £96m and £144m annually.
While there has been a real focus on protecting vulnerable adults in care homes, we should not lose sight of the support and services that are given to vulnerable adults in the community – those in assisted/supported living, those in extra care accommodation or in shared lives accommodation and particularly those receiving domiciliary care at home. Increased service demands and pressures are being felt by care at home providers, particularly in relation to rehabilitating those post-COVID patients who have spent long periods in hospital or who are suffering Post COVID Syndrome (Long COVID). We are concerned that there are domiciliary care supply and demand gaps emerging in some parts of Wales following high levels of D2RA discharges from hospital into community settings. Our members are still developing care packages for citizens who were affected by the first wave of the pandemic, let alone this second wave and any further waves that might emerge in the new year.
Children’s services
Children’s Services were already under pressure before the impact of COVID-19. Our members have concerns around the impact on children’s wellbeing during the pandemic. Despite the continuing and increased provision by children’s services, many other provisions that promote early intervention and prevent the escalation of need and risk, were adjusted or stepped back in a myriad of ways, the accumulative impact of which is yet to be assessed. Bearing in mind the multiple jeopardy faced by vulnerable families during protracted pandemic conditions, additional demand is sadly predicted with uncertainty about the precise nature of excess demand. This, coupled with pre-existing marketplace constraints in relation to placement costs and underlying workforce issues, means that we will see continuing financial pressures arising from the pandemic in the longer term, something which the WLGA highlighted in their evidence to the Committee in September.
The number of looked after children has increased over the period of the pandemic and placements are increasingly difficult to source. A review of the data and our current circumstances mean that despite promising progress in many areas, looked after children numbers will not reduce in line with the trajectory of expectations. We know that the level of demand for independent provider placements, including higher cost placements to meet complex need continues to rise. Equally, the insufficient availability of suitably experienced social workers has led to many authorities relying upon agency staff and thus the cost is magnified.
However, it should be noted that whilst the numbers of looked after children in the care system have increased slightly over the period of the pandemic, the rise was only marginal. This is quite remarkable considering that schools were shut for several months and that domestic violence increased significantly. It demonstrates how proactive local authorities have been in working with families, particularly those on the edge of care, preventing an expediential growth in numbers.
Personal Protective Equipment (PPE)
This was probably one of the most challenging issues to overcome during the first critical response phase of the pandemic. Establishing secure, consistent and appropriate supply of PPE for social care services, including supplies for care home providers, took several weeks to finalise and achieve and certainly caused a high-level of anxiety amongst our members. So much so, that ADSS Cymru’s President wrote to both the Welsh Government’s Director General and Deputy Director General of Health & Social Services Group, on 31st March 2020, raising a number concerns about access to PPE and the potential impact of supply failure, including the inequity of supply compared with the NHS; that PPE guidance for the social care sector was being tailored to the supply of PPE rather than risk to staff and vulnerable people; that there was a lack of a co-ordinated community testing policy, which was ensuring the demand for PPE remained high; and the risk of increase deaths in residential care settings was not being given suitable national attention.
Following this letter, we welcomed the opportunity to work with officials to shape new guidance and PPE protocols in various care settings in Wales. ADSS Cymru members worked proactively with the military during their review of PPE supply chains and distribution networks and through our members, we have ensured that the learning and best practice models highlighted by military logistics officers have been shared.
While the supply of PPE has improved considerably over the last few months, we must be cognisant of the demand through this winter period, which has seen various local outbreaks, and could put pressure on supplies. Therefore, it is important to ensure that regional joint stores have sufficient levels of the right pieces of PPE, ready for any eventuality that occurs, that includes additional pressure placed on the sector by the end of the UK’s period of transition.
ADSS Cymru has welcomed the opportunity of working with Welsh Government and NHS Shared Service Partnership to streamline the process of purchasing and distributing PPE, to ensure that social care staff working on the frontline in various care settings have the confidence to deliver personal care, without putting themselves or the citizens that they care for, at undue risk.
Testing
Similarly, as to PPE, the challenges of implementing a robust testing regime for social care has been extremely problematic and well documented. There have been several difficult elements in this process, which includes trying to work with Public Health Wales to provide a clear strategy on testing for staff in social care (particularly community care), insufficient and inconsistent capacity in the early weeks, the distances staff were required to travel to be tested, getting tests processed and turned around in a timely manner and getting those results back to care staff (the back-end process).
Another significant challenge has been around the testing and discharge of patients out of acute care back into residential and other community care settings. During the early phase of the pandemic, ADSS Cymru members pressed the Welsh Government to roll out a medical protocol in relation to admissions to care homes from hospital because Directors and local authority commissioned Providers were being placed under significant pressure by Health Boards to admit people into care homes without receiving a COVID test. Many Directors were not prepared to sanction these discharges, particularly while there was still so much capacity left in hospitals at the time. The whole situation has resulted, in many parts of Wales, with a significant breakdown of trust between care homes and hospitals, which will take some time to repair.
However, what exacerbated this was the delaying in Welsh Government publishing its discharge guidance, which came some two weeks after the UK Government published its guidance for England. This was further complicated with some Health Boards not adhering to that guidance when it was published.
Initially, there was some inconsistency how this protocol was implemented but, in some regions, Health Boards have work closely with local authorities in care homes where there were specific outbreaks, with a view to developing a consistent regional process and that has worked well.
The problem with asymptomatic members of staff has been a challenge in care homes and we welcomed the move to weekly testing for care home staff in June which continued through to October. Moreover, we have also welcomed the testing flexibilities that Welsh Government have provided authorities from November, which allows an options-based approach (weekly or fortnightly) which is triangulated using guidance, local data/intelligence and professional judgement.
As the number of tests being undertaken in care homes has increased, there are concerns being highlighted where a home may have a high number of positive results, particularly amongst staff members and the impact this may have on services and care. The Support for Commissioned Providers guidance has encouraged commissioners to work with providers on enhanced business continuity plans to build in resilience and sustainability. A third iteration of the guidance is currently being finalised.
ADSS Cymru welcomes the commitment from the First Minister to improve the turnaround of test results with the aim of providing results within 24 hours, however concerns remain about the amount of time being taken to get results back and it is essential that this is resolved as a matter of urgency.
Moreover, there are also concerns about the lack of testing of domiciliary care workers, which consequently could make them an unwitting reservoir of community infection. This cohort of the social care workforce must be tested on a regular basis. We understand Welsh Government have piloted a testing model using both real-time reverse transcription polymerase chain reaction (rRT-PCR) test and the Lateral Flow Antigen test. It is critical that the evaluation process for the pilot is undertaken at pace so it can be rolled out as soon as practicable.
Vaccinations
The planned roll-out of vaccinations from early December is going to be critically important. As well as vaccinating our most vulnerable citizens, it is vitally important that frontline social care workers are vaccinated at the same time as health workers and the type of vaccine and logistics around that need to be comprehensively thought through; for example, for staff working out in the community, which vaccine will be administered and how will it be administered? And what considerations are being taken about staff who have auto-immune conditions and are unable to receive a live vaccine?
Also, the communication of the roll-out it also extremely important. The messaging needs to be appropriate and targeted and pushed out quickly before the roll-out commences so that our citizens, our workforce and our care providers are very clear what their roles and responsibilities are during this extremely important phase of the pandemic.
Workforce
The social care workforce has been extraordinary during this first critical phase of the pandemic. ADSS Cymru welcomes the recognition both the Welsh Government and wider Welsh public have afforded the sector, which has ensured they have remained high in the public’s consciousness over the past nine months. Parity of esteem in terms of pay, working conditions and recognition, have been seen as critical elements in ensuring the long-term sustainability of the workforce moving forward. It is essential that social care workers, including those working in care homes, are offered the same opportunities and conditions as NHS workers.
It cannot go unnoticed that the outbreak has had a devastating impact on people working in social care; particularly those working in residential care. When adjusted for age and sex, social care workers have twice the rate of death due to COVID compared to the general population.v The intense pressure on these workers and the impact on their current and future mental health and wellbeing continues to be a source of concern for ADSS Cymru’s members.
It has been well documented that the coronavirus has had a disproportionate impact on BAME health and social care workers than their white colleagues. ADSS Cymru has ensured it has had director input on the Government’s COVID-19 BAME Advisory Group. They have examined ways to mitigate the impact of the pandemic on this workforce group, including producing employer toolkits and a risk assessment document for BAME workers, as well as information materials in a variety of different languages and accessible formats to communicate key coronavirus messages, around issues like Test, Trace, Protect (TTP).
ADSS Cymru has welcomed the introduction the social care worker card by Social Care Wales and Welsh Government and our members were part of a working group which enabled its development and implementation. ADSS Cymru has also welcomed the £500 bonus payment for social care staff and welcomed the opportunity to work with Welsh Government to ensure that the payment is optimised and financially efficient. However, where support has fallen short is in relation to other benefits received by NHS workers, like free access to public transport, to allow social care workers to have the same freedom to move between their homes and places of work, as well as access to mental health support services. This must be remedied as a matter of urgency.
However, while these benefits have been welcomed, ensuring that social care staff have equal access to PPE, testing and vaccinations as health care staff, is absolutely critical to allow them to effectively undertake their caring duties.
Over the medium to longer-term, we are concerned about the physical and mental toil the pandemic will have taken on the workforce. That is why we welcome Social Care Wales expediting the well-being theme of the national integrated workforce strategy because it is going to be vitally important that all the support mechanisms are in place to aid workforce recovery.
Data
The pandemic has highlighted the paucity of data that existed both in Wales and externally, around key social care indicators. For example, the data the Office for National Statistics (ONS) held on registered care settings in Wales, was woefully out of step with the data that CIW held and significantly skewed the statistics around death rates during the early weeks of the pandemic. The data gathering work that the ONS had previously undertaken with Care Quality Commission (CQC) and the Association for the Directors of Adult Social Service (ADASS) in England, had ensured that English datasets were far more accurate and up to date. This demonstrates the importance of having up-to-date data and intelligence about the incidence of COVID-19 in all care settings but particularly care homes, to aid the targeting of help and support in any identified hotspots.
ADSS Cymru members have welcomed the opportunity to work with colleagues in Welsh Government, CIW and Data Cymru, to identify, gather and share information that would be helpful to policy makers and care professionals, to understand where current and existing pressures may emerge in areas like the workforce, with testing, with safeguarding, with care setting capacity and demand, all of which are important checkpoints to understand an authority’s ability to operate effectively at any given point in time.
Innovation and sector improvement
As social care leaders, we take the innovation and improvement of the sector extremely seriously and it is a driving factor in everything that we do. However, our members could be forgiven for not progressing this agenda whilst trying to manage a public health emergency. However, despite the pressures placed on the social care sector by the pandemic, local authorities have taken the opportunity afforded by the situation to innovate, reconfigure and develop new services to meet citizen need.
There have been significant changes in the way people have worked in response to the pandemic, with the greatest impact being on the increased and improved use of digital platforms and technology and the need to work from home. While in the early stages, some authorities may have felt like they were not geared up for home working, many of our members have been surprised at the speed in which their organisations were able to adapt to this new way of working. Having the ability to remain flexible and adaptable to change has been vital as things in the early stages of the pandemic were changing on an hourly basis as new information became available. Moreover, the sense of urgency created by the crisis meant that it was easier to be more focussed, as all partners were working towards delivering a common purpose which resulted in decisions – sometimes very difficult and complex decisions - being made more quickly, with a lot more being achieved in a short timeframe.
What has also emerged to some extent during the pandemic is there has been a shift in the level of support that some services users have required. There have been many cases of citizens who have previously accessed services because they required support having found other ways of coping without the extent of the service they had previously been in receipt of. It is not clear what impact this will have on citizen expectation and service delivery in the longer term and whether this is because family/friends have been able to fill any gaps in care and support while their work patterns had changed. The various lockdowns and restrictions have provided an opportunity to further embed the principles of the Social Services and Well-being (Wales) Act across local authority corporate customer services who are now focussing on asking people “what they can do for themselves rather than what do they need?” This may have the effect of looking in more detail at the amount of time spent on assessments with a stronger focus on the most vulnerable.
Some service innovation examples are:
- Good Turn Scheme – Good Turn Schemes had been identified in the Older People’s Strategy and the plan was to develop this over 2 years. The pandemic gave this increased impetus and there will be 10 up and running in the next 2 months. The local authority involved moved quickly to get the governance arrangements in place, funding for mobiles, laptops and training for telephone coordinators.
- Digital Companions - One authority is developing Digital Companions for those 80+ living in the community who do not have access to the internet and do not use digital technology. This has been accelerated and a website will provide a direct line to a virtual community hub and connect a digital champion to the individual.
- Newid App – One authority has undertaken further development work on an application that it uses - ‘Newid’ App, (a Children’s Services App only available on iPad) - for families and key workers. Key workers are able to share screens and do activities with the families over the App, which has worked really well and families have enjoyed it. This good practice model has been shared and other local authority areas have also started to use this App.
The WLGA is hosting a repository of good council practice that has taken place during the pandemic on its website, which covers many examples within both adults and children’s services - https://www.wlga.wales/good-council-practice-covid-19
References:
i Delivering Transformation, Innovative Funding Models to Meet Social Care Needs, ADSS Cymru, 2018.
ii Delivering Transformation, Rebalancing the care sector: A Report on Adult Services, and Rebalancing the care sector: A Report on Children’s Services, ADSS Cymru 2019.
iii Delivering Transformation, Mapping co-operative provision in domiciliary care, ADSS Cymru, 2019.
iv Delivering Transformation, Technical advice to improve integration and support the use of pooled budgets, ADSS Cymru, 2018.
v https://www.health.org.uk/news-and-comment/charts-and-infographics/what-has-been-the-impact-of-covid-19-on-care-homes-and-social-care-workforce
