Oral evidence: Adult Social Care workforce, HC 690
Oral evidence, 28 February 2018.
Witnesses
Sharon Allen, Juliet Chua, Jo Farrar, Glen Garrod, and Sir Chris Wormald.
Chair
Good afternoon and welcome to the Public Accounts Committee on Wednesday 28 February 2018. Today, we are examining the Department of Health and Social Care’s progress against its priority of supporting the care workforce. We know there are huge issues here around skills and funding, and issues facing a lot of the providers as well as the workforce, such as national insurance payments and the ongoing question of night care. Clearly, this workforce is critical to providing good-quality care for an ageing population. The demand is growing, yet there are huge stresses on the workforce. In fact, the CQC says that the sector remains “precarious”. We know that the workforce is under great stress for many reasons, in terms of turnover, pay levels and qualifications. We are going to probe some of these issues. Of course, the Department has strategic responsibility for oversight of all of this. I will introduce our witnesses and then direct a couple of questions at you, Sir Chris, before we get into the main session, if that is okay. Even if it is not okay, we are going to do it; the veneer of politeness is simply that. From my left to right we have: Sharon Allen, the chief executive of Skills for Care. Welcome to you. I think this is the first time you have been in front of this Committee. Is that right?
Sharon Allen
That is correct.
Chair
Welcome. We have Sir Chris Wormald, who is a regular here as permanent secretary at what is now the Department of Health and Social Care; Jo Farrar, the director general for local government and public services at the Ministry of Housing, Communities and Local Government—we do have a lot of name changes today, don’t we?—then we have Juliet Chua, the director of social care and transformation at the Department of Health and Social Care; and Glen Garrod, the vice president of the Association of the Directors of Adult Social Services—so he is a direct local authority voice here on the panel today. Our hashtag today is #socialcare. Sir Chris, how much has it cost to rebrand the Department as the Department of Health and Social Care?
Sir Chris Wormald
Very little indeed—I think a few thousand so far.
Chair
So far—okay.
Sir Chris Wormald
We have taken the view that we will replace things only when they run out. So we have updated all our websites and those sorts of things—
Chair
So we might get still the odd letter saying Department of Health.
Sir Chris Wormald
Yes. The letter headings, business cards and all those sorts of things still say Department of Health, and we will change them when we run out. We took a view—
Chair
Common sense has broken out—that is heartening news. So a few thousand so far. At some point, we would like to know how much it will cost.
Sir Chris Wormald
I can send you an exact update—
Chair
That would be good. I won’t ask Jo Farrar the same question as it is a bit unfair to ask you—as you are not permanent secretary—but we will write to your permanent secretary to ask the same thing.
Jo Farrar
I will let her know.
Chair
I think the Department of Health and Social Care has set a good example there. I look forward to receiving letters on old-fashioned headed paper, knowing that you are saving pennies which add up to pounds for the taxpayer. The other thing that has been very much in the news recently is the drug errors in the NHS linking to a number of deaths. Do you want to update us on that, since the publicity last week? It is obviously a very serious concern to patients out there, and particularly to family members who may not be the patient but are worried about their vulnerable family member getting the wrong drug treatment.
Sir Chris Wormald
Yes, it is an extremely significant issue and, as you say, the Department made a series of big announcements last week. I will write to you with the full details, but essentially what we were trying to do here was shine a light on an area that has been under-researched before. There is no evidence at all that there are more drug errors in the UK than in any other jurisdiction, because basically no one has looked. We believe we have done the most comprehensive piece of research anywhere in the world on this subject to quantify the issue, which hopefully gives us a strong baseline to begin to bring those numbers down. Of course, within that very large number of drug errors we identified, there are lots of different things going on. Some of those errors will be comparatively minor—a drug given a few hours later than it should have been that does not lead to patient harm—and in other cases it is about a much more serious error, where it does lead to patient harm. That is where our biggest philosophy lies. There is no single answer to what you do about it, because it is a huge delivery chain—I think we have about 1 billion prescriptions a year in the UK, and each of those has four or five steps to it before it gets to the patient, so we are talking about an enormous system. What we really need is controls at each stage of that system, including measures such as widening the use of electronic prescribing, which eliminates quantity errors and those sorts of things. A lot of the errors are where people are on multiple drugs and it is about how those drugs interact, because of course it is not unusual for older people in particular to be on eight or nine drugs. We need to be much more thorough about doing the pharmacist’s drug review of the entire drug intake of the individual, as opposed to of each individual drug. There is a whole series of things we will want to do. Although the numbers are obviously not what you would want, we are pleased to have publicised this important issue for pretty much the first time.
Chair
We would applaud you for publicising it, but, as you say, it is a challenge for you as a Department to deal with it when there are so many different providers delivering it.
Sir Chris Wormald
Yes.
Chair
It was quite alarming to see that the research estimates that 71% of annual drug errors occur when patients see a GP or practice nurse. Do you have any particular plans to work with GP surgeries to make sure those errors—
Sir Chris Wormald
We will be looking across the piece, including in that area. I should emphasise that—
Chair
Could you give us a precise example of what you are planning to do that will help with it practically on the ground, at GP practice level?
Sir Chris Wormald
As I say, I can set it out in detail for you in writing, but one of the biggest things is that we are putting far more pharmacists in GP practices. That is a big practical thing, so you have advice on correct prescribing right there. That is a very big thing.
Chair
You say you are doing that, but that is quite a challenge for some GP practices that do not have the space. Practically, does that mean more money is available for GP practices to be able to build—
Sir Chris Wormald
There is quite a big programme around that; as I say, I can set out the details for it. I should say that, of course, this is something we do with all our partners in the health system. If you took the GP example, it would be an NHS England lead, but there are a whole series of programmes that we are doing. As I say, I would not like to leave you with the impression that there is some silver bullet here. It will be lots and lots of little actions.
Chair
When in the strategy will you see an appreciable difference? Are you going to do this research regularly to check up on progress?
Sir Chris Wormald
Let me check when we are next reviewing.
Chair
You know we love having dates and deadlines to hold you to account on.
Sir Chris Wormald
I would not want to promise a date I could not promise you was accurate.
Chair
You have learned to be cautious, Sir Chris. It is a very serious issue and we are keen to keep an eye on how progress is being made. It is very easy for a Secretary of State to make an announcement—not to denigrate a Secretary of State—but we want to make sure that there is follow-through. We will pick up on this again.
Sir Chris Wormald
Just on that last point, we would completely welcome that. One of the things we wanted was much wider debate and publicity on this issue, so your scrutiny will be welcome, as always.
Chair
Thank you very much, Sir Chris; you are in a good mood today. I am now going to bring in Sir Geoffrey Clifton-Brown to see whether he can stoke that good mood or dampen it.
Sir Geoffrey Clifton-Brown
I am sure you will have something to tell us on what I am going to ask, Chris. It is a follow-up to the questions the Committee asked you a month or two ago about the drugs companies deliberately rationing drugs to increase the price. Of course, we have had this celebrated case of the skin cream costing £1,600. What is your Department doing to address those problems?
Sir Chris Wormald
The National Audit Office is now doing an inquiry on exactly that subject, I think. I am not quite sure what your timing is, Amyas.
Sir Amyas Morse
In a few weeks we will be able to report on what you are doing about it at a certain point.
Sir Chris Wormald
We expect the Committee to come back to that. What we have been doing is exactly what I described in my letter following the previous description. At the moment, all or most of our powers in this area are informal pressure; we have very few powers of direct regulatory access. We have seen prices stabilise since the initial spike following our conversations with the suppliers and the drug companies, led by our new chief commercial officer, who is leading all of this for us. We did not continue to see the rises that you and others were concerned about. We have always relied in this area on a free market to deliver us the best price, which it traditionally has. The question going forward—the NAO’s assessment will inform this—is whether that is still right and whether it still delivers us the lowest prices, which it has done previously. Secondly, we get our new powers in the next financial year under the recent Act, so the question is how we should best use those powers to avoid the situation we saw.
Sir Geoffrey Clifton-Brown
The problem is the concentration of certain drugs in the hands of certain drugs companies, which means they are able to restrict supply so that they can increase the price to you. The market may not operate as it should to deal with that problem.
Sir Chris Wormald
Yes, exactly.
Sir Geoffrey Clifton-Brown
Do you think the new Act will give you the powers you need?
Sir Chris Wormald
The new Act gives us considerably more informational powers. At the moment, most of the information we get out of the market is voluntary rather than compulsory, so, first, we should be able to identify much more easily and much quicker where the market is working and where it is not working. Secondly, it gives us more regulatory powers where we think the market is not working. However, these are quite nuanced judgments, as I say. Across the piece, certainly our previous analysis has shown that the UK has massively benefited from having a basically free market, and there is quite a lot of evidence that we have had lower generic prices than those jurisdictions that have traditionally regulated. As you know, it is quite difficult to partially regulate a market. I do not want to give the impression that we will have regulatory powers and suddenly everything will be different. We will have to balance the benefits we get from what is normally a vibrant market that keeps prices down by itself and those areas, such as the ones you have raised, where the market does not appear to be operating as it should.
Chair
This is something we definitely want to keep an eye on.
Sir Chris Wormald
I am assuming that, following the NAO Report, you will want to have a hearing specifically on that.
Chair
You will have to wait and see, but the chances are—you have gauged our interest. Before I hand over to colleagues, we are obviously asking every permanent secretary what their Department is doing to prepare for exiting the UK. In the context of this Report particularly, a large percentage of adult social care staff are EU citizens, and their number is great. Is this something that you are calculating? Are you putting in place plans to make sure that the sector can survive the shock if there is a change—it depends on exactly what the final deal is—for people who are in jobs now?
Sir Chris Wormald
Yes. As you say—some of my colleagues might want to comment about how this looks to local government and the provider sector—EU citizens and indeed citizens from non-EU nations play an extremely important part in the care workforce. Of course, their contribution is hugely valued, as the Government have said on a number of occasions. So far, in terms of the national numbers, we have not seen a decline in the percentage of the workforce that comes from the EU: it has been relatively stable at around 7%.
Chair
So they are still in there now, but you will have a problem with the pipeline being cut off.
Sir Chris Wormald
Yes. Our next set of numbers comes out in the summer, I think, so we will get updated numbers about whether that trend is continuing in the summer.
Chair
Just to be clear, these are people currently in the workforce, and they are not leaving because they are EU citizens, but there is—
Sir Chris Wormald
Yes, at the moment it is stable. There is then, as you say, a series of questions, which are not so much about exiting the Union—they are as much about the future of immigration policy. I cannot tell you exactly what our answer to that is, because of course it has not quite been settled.
Chair
Is it one of your EU work streams?
Sir Chris Wormald
Yes, it is. It is one of our four biggest EU work streams. We are in close dialogue with our colleagues at the Home Office on this issue, and we will continue to monitor it carefully. It is right at the top of our agenda.
Chair
From the work you have done so far, how much lead-in time do you need if there is going to be a change to immigration rules or if you are going to lose a lot of new arrivals from the EU overnight who are needed to care for people in the UK? If the Home Office made a decision on this in the summer, would that be enough time for you to adjust your plans?
Sir Chris Wormald
In the social care world, it is very, very difficult to say, because of course there are lots and lots of individual employers—people are not directly employed by the state—and this is an issue that affects parts of the country considerably more than others. I think the vast majority of those people are in London, the south-east and the south-west. I cannot say exactly that if it’s by this date, that would be all right, but we are looking at it carefully.
Chair
Have you done a similar calculation for the NHS workforce?
Sir Chris Wormald
We do the same processes for the NHS workforce. Of course, in some areas—for example, for doctors’ numbers—we have already made it clear that we wish to become self-sufficient over time.
Chair
That’s all very well for the future if that’s possible, but in the here and now the NHS is propped up by, among others, EU workers who will not be allowed to come in in the future.
Sir Chris Wormald
I’m sorry, but you can’t make that assumption. That is about where we set our future immigration policy and, as I say, we are discussing that with our colleagues at the Home Office. If you take one of the things we are discussing today—social care nurses—that is on the shortage subject list, and we continue to import them from beyond the EU as well as from the EU. The Government will have to take decisions about what it does with those categories of worker going forward. I can’t tell you what they are because they haven’t been—
Chair
It’s just that Brexit is just over a year away. It sounds a bit vague at the moment, if I may say so.
Sir Chris Wormald
Those decisions have not been made yet.
Chair
Are you giving good advice to Ministers about the needs of our national health service?
Sir Chris Wormald
Yes. As I say, this is right at the top of our priority list.
Chair
It’s not just the numbers, is it? It is about the welcome or the lack of welcome that some staff perceive. They have given up their lives in other countries to come and work in our NHS, and they feel that they are not wanted now.
Sir Chris Wormald
Yes. As I said at the beginning, the Government has repeatedly made clear the huge value it places on the contribution that those people make to our NHS and our care system.
Sir Geoffrey Clifton-Brown
Sir Chris, this is clearly a really important point for both the social care sector and the NHS. Are you making representations to the Cabinet Office to say that, whatever changes take place in the immigration regime, there will be a need for some form of health worker visa to allow exceptions to whatever immigration policy might emerge?
Sir Chris Wormald
Yes. I am not going to set out what our advice to other bits of Government is, for the usual reasons, but we discuss those things with our colleagues at the centre of Government and the Home Office all the time. A number of health professions are already on the shortage subject list. The Government already looks at the needs of the health and care workforce and adjusts its immigration policy accordingly. As I say, I can’t describe the exact conversations for reasons that you understand, but this is right at the top of the issues we are looking at.
Chair
One of our concerns is about the interaction with the Government. The Home Office is going to have to have an EU migrant scheme in November on top of its existing visa scheme. It has already reduced indefinite leave to remain, so you have to renew it every couple of years until you get to the level at which you can claim citizenship, so it has got a lot more work going on. We are not asking you to give an example at this point because we recognise it is not a policy decision you have made or can make, but if there was a visa scheme of the kind described by Sir Geoffrey Clifton-Brown, your Department will be heavily reliant on the Home Office to get it right and to meet certain deadlines. Do you have confidence that the Home Office are going to deliver this?
Sir Chris Wormald
We and our Home Office colleagues have very close dialogue about these things. As you say, these are not easy issues, but the joint working is very good. We have a group, which Jo chairs, that looks specifically at the local government workforce. The machinery to do all this is in place. For the reasons you set out, these are not easy issues. Jo, do you want to say a bit about that?
Chair
We are all concerned about the timescale, Ms Farrar.
Jo Farrar
The UK’s agreement with the EU on citizens’ rights obviously allows people to continue to live here during the implementation period. That gives us time to work with Whitehall colleagues to work out what a smooth transition would be. It is only one of a number of issues that relates to the social care workforce. We look at everything in the round, but we are looking at about 7% of the workforce, so it concerns us. We are working closely together to find the right solution.
Chair
We obviously need to probe this more. We are concerned because we have heard from other permanent secretaries that deadlines are looming—there is just over a year to go—to make decisions so schemes can be implemented. The summary of that exchange is that it is a bit vague still. You may be having conversations behind the scenes, but we need concrete results. The staff working in our NHS—be they staff who are EU citizens and are worried about their future or staff working alongside them who are worried about their leaving—need reassurance. I am sure you have got the point. I am going to hand over to Gillian Keegan, who is going to kick off for us on the social care workforce. Over to you, Gillian.
Gillian Keegan
You cannot open a newspaper nowadays without reading about concerns about social care. It is everywhere. How do you go about ensuring there is enough funding to meet the needs of the population?
Sir Chris Wormald
I will ask some of my colleagues to comment as well. Essentially, in the last spending review, we did an assessment of needs going forward. That is what the spending review was predicated on. I don’t think anyone on this panel or anywhere else would deny that this is a sector that faces significant financial pressures. That comes out in the National Audit Office Report. It also comes out in the CQC report on the state of care. It is something that we are both concerned about and know we will be needing to take further action around, particularly in the upcoming Green Paper in the summer. Locked in your question is the very important question of sufficient funding for what? In terms of local authorities fulfilling the statutory duties set out in the Care Act 2014, there is one local authority, which was in the news this morning, about which we are concerned. That is Northamptonshire, and we can talk a bit more about whether they are continuing to fulfil their statutory duties. Other than that, when we look across the local authority sector, they are fulfilling their statutory duties as set out in the 2014 Act. What has happened around funding, which comes out in all the numbers, is of course that local authorities have been focusing on their statutory responsibilities and making savings in their discretionary areas of spend. So we have seen the total number of people receiving care go down over the last few years, but as I say, not below the statutory minimum that Parliament set. As of today, we think that there is sufficient funding in the system to fulfil those statutory duties. Funding does then begin to go up over the next few years.
Chair
We know the funding pattern so you don’t need to go into the detail.
Sir Chris Wormald
But, as I said, as the CQC has reported and the NAO has reported, there are quite clear funding challenges for local authorities and the private sector going forward.
Chair
And we have read those reports. I am going to bring Gillian Keegan back in. We are going to have to have slightly shorter answers, or you and the team could be here for a long time. It is up to you.
Gillian Keegan
It is clear there is huge challenge. Actually, everything is a challenge in the social care sector. It seems to me that we have a system that is designed for 20 years ago, as opposed to one that is designed for either the situation we are in now or, more importantly, the situation that we know we are heading into. Do you feel that you have the right kind of strategy to get the right system for the needs?
Sir Chris Wormald
We believe we are developing the right strategy. I don’t think we would say we are there yet.
Gillian Keegan
What caused you to develop that strategy? The inputs of what has changed between 20 years ago and where we are heading, or where we are now, have all been relatively predictable: population growth, population movements, expectations, longevity and so on.
Sir Chris Wormald
I would say a few things. As we have discussed with this Committee before, there is a whole series of issues around social care that have been known about for decades and for one reason or another have not been taken forward by a succession of Governments—integration between health and care and all those sorts of issues.
Gillian Keegan
Are you saying it has been deliberately ignored?
Sir Chris Wormald
No, it hasn’t been ignored. It is just incredibly difficult to do. As I think I have said to this Committee before, I think the first Government White Paper suggesting integration was in 1963, and almost every Government since then has had objectives around that. It is just very difficult. What has prompted where we are now? Obviously, there is a big public debate around social care, as you say, and it was heavily debated during the last general election. Clearly, the changing demographics and the financial position affect that considerably.
Chair
We know that; Ms Keegan laid that out. She was asking, very precisely, what you are doing to project forward and plan.
Sir Chris Wormald
The question was why we have changed.
Chair
So can you give us some examples of what you are practically doing?
Sir Chris Wormald
There is a whole series of things that I might ask Juliet to describe about the current system, but there are two big things coming up. First, on the specific question that we are considering today, we are looking at revamping our workforce approach through part of the Health Education England consultation that Skills for Care is running towards a workforce strategy in this area. Secondly, there is the upcoming Green Paper. Those are the two big practical things going forward.
Gillian Keegan
Sorry, you had workforce approach, and what was the second one?
Sir Chris Wormald
The summer Green Paper that the Government have promised about social care in general. Those are the two bits of development work that we are doing that are different from the previous—
Gillian Keegan
Will that include demand side? You have two elements of this, in terms of designing the strategy: the supply side and the demand side. On the demand side, the projections of need have been clear for a long time. How are you including the supply side in your strategic analysis? It is very fragmented.
Sir Chris Wormald
Yes. In some ways that can be a strength of the system, and in some ways that can be a weakness. Those are issues that we are looking at in the production of the Green Paper. Do you want to say a bit more on that, Juliet?
Juliet Chua
I would observe that in the short term, within the current legislative framework, in the Care Act there was an expectation that local authorities have a duty to market shape, to think about what the supply side is in the local area, to counter that, to recognise the demand, and to play a role in thinking about what need there is and how to plan for it.
Gillian Keegan
How confident are you that that is actively happening?
Juliet Chua
We know that that is variable. That comes through both in the most recent CMA report on the residential care market, and it has come through in the NAO Report. We know that there is more to do in that space, and that is something that we want to continue to develop. In terms of looking forward in the Green Paper, as was set out in November we recognise that there are some quite big, complex questions regarding a long-term or sustainable system on social care. We are talking to a range of experts to draw in a range of perspectives to publish in the summer. To your point, that has to take account of both demand and supply.
Chair
Can we just be clear? It is all very well saying that local government needs to shape its own market—Glen Garrod may want to comment on this—but national insurance contributions are going up, which is a Government issue. Skills training is a strategic element that Government need to deal with. The legal challenges about overnight stays are a bigger issue than the local authority can deal with. Those issues are very squarely with the two linked Departments of Government.
Sir Chris Wormald
Absolutely, and we are not challenging that at all. The way that the system works, we have responsibility for the overall framework and the Care Act then places some very specific duties on local government, one of which is to shape the local market for care. Juliet is simply describing the law as it applies to local authorities. Even within that, as I think we have discussed with the Committee before, for providers of national importance we take a national overview through the CQC assessment system. For those providers who span mini local authorities, we take a national oversight, and then it is for local authorities to shape their market in their particular area.
Chair
We have talked a lot about shaping the market. Maybe Glen Garrod could give us an idea of the challenges of shaping the market for local authorities?
Glen Garrod
Would you allow me to go back to your first point about Brexit? You are absolutely right that the level of exposure to EU and non-EU nationals is particularly profound in the clinical grades—doctors and nurses. I should express a personal interest in that matter: my wife is a German national, and a GP who has worked in the NHS for 25 years. How she feels about how welcome she and many of her friends are in this country is in part a reflection of where the nation is going. That means that some people are beginning to think about whether they want to stay because of whether they feel welcome or not. That is quite profound.
Chair
You are here as the Association for the Directors of Adult Social Services. What is the impact in that area for social services directors? How are you managing that in social services?
Glen Garrod
One of the problems with many years of reductions—some £6.3 billion since 2010 on social care—is that you reduce your capacity to cope when times are tough or when you need some flexibility in the system. That means small changes have much bigger effects. A loss of nursing in the residential sector in consequence of non-EU or EU nationals leaving is quite profound.
Chair
Have you seen an example of people already exiting the sector?
Glen Garrod
Yes.
Chair
What sort of numbers are we talking about there?
Glen Garrod
It depends which part of the country you are in.
Chair
So it is very different. What about this shaping the market thing that Juliet Chua mentioned? She outlined the law, which is all very well, but how has it been in practice for your members trying to shape the market in different parts of the country?
Glen Garrod
The market position statement requirements came in with the Care Act, which was enacted in 2015, so they are still relatively new. It is important to recognise that there are two national policy programmes, the Better Care Fund, and sustainability and transformation plans, both of which are pushing in the same space of sustainable systems and integration. Both are very thin when it comes to workforce. It is important to recognise that the policy context in which we operate can be either helpful or a hindrance. At the same time, we have market position statements, and some colleagues are progressing them in a much more sophisticated way when it comes to workforce development.
Chair
Can you give us an example of a good one?
Gillian Keegan
I have studied business for years and I have worked in it for 30 years. I did not understand a word of what you said about how what they are doing will shape a market. Can you explain what they are doing, or can do, practically to shape and influence the care market in their areas?
Glen Garrod
Two or three things, if I may. The first is that what you buy can be a factor not just of how much you pay for it but of the nature of how you make the payments. Are you funding for three to five years, or are you paying on a one-yearly contractual basis? Are you spot purchasing or block purchasing, which gives some security of tenure to the person who is supplying that service because they know how much they are getting? It also commits councils to making that funding available. In my own council we have a three-year funding arrangement with both the domiciliary and the residential sector. A number of colleagues, like us, have also structured the independent sector, which is mostly small to medium enterprises, so that they work more closely together and can provide support to each other, for example with unit managers in residential settings. In Lincolnshire it is not uncommon for a unit manager to be newly appointed into a 30-bed unit where the proprietor lives abroad and they have no support. That is a difficult thing to do on the pay grade they are at, so our sector, as a strategic partner, now provides training and mentoring for those unit managers. If CQC were in the room today they would tell you that well-led equals safe. There is a cause and effect between those things.
Gillian Keegan
I guess I have a more strategic issue, which is that we know there is a problem with many councils not paying even the benchmark for care. They are certainly paying a lot less; I think the differential between self-funders and councils is 41% at the moment, and it will probably increase. It depends on certain areas. In an area with a lot of self-funders, how will you shape the market so that people needing care from the council are not excluded from the market? On the other side of the equation, in councils that have only council, how do you make sure they are sustainable when there is no cross-subsidisation from the very few self-funders? I understand that you buy upfront to get this lower price to some degree, but I am a bit concerned when you look at some of the reports on shaping the market. It is a risky, labour-intensive, capital-intensive business; why would you put your money into it if you are in one of the out streams that is either all self-funders or largely council-funded? How would you shape the market in those scenarios? What are your levers?
Glen Garrod
The first thing to say is that England is not one space. There are many markets.
Gillian Keegan
That is why I described two extremes. In fact, I had Liverpool and West Sussex—where I am from—in my head.
Glen Garrod
That is one of the reasons why local market-shaping is critical, because you better understand the—
Gillian Keegan
But are those just words? Or do they actually have the tools to shape the market?
Glen Garrod
In large measure, I think they do. There is a question about whether there are sufficient resources within councils to do that well enough, along with the skill set that is required. If you are a council experiencing severe financial constraints, you will prioritise frontline services over a number of back-office functions. That is almost inevitable.
Chair
But that is not shaping the market, is it?
Gillian Keegan
These are very reactive statements.
Chair
Jo Farrar, you are dealing with the strategy of this. How are you working with local authorities at the centre?
Jo Farrar
I was also local government chief executive in 2015, so I had some experience of that. As Juliet said, the picture is mixed, but a lot of local authorities are good at shaping the market. They will get to know their local providers. They will set out a long-term strategy for the type of care that they need and they will do that in discussion with providers in the area, to help to shape the right conditions. We in Government, particularly since the spending review, have tried to give local authorities additional funding to help them to shape the market for their local area.
Chair
Can you give us some examples of that?
Jo Farrar
We have given them access to £9.4 billion in the last four years.
Chair
What have they done with that money?
Jo Farrar
For example, Lambeth Council is paying for home care providers, so that they can pay the London living wage. That gives more sustainability to the home care market and helps to shape that. In other places, such as Milton Keynes, the council is using its precept funding to help major adaptions to help people live independently.
Chair
Sorry, you said precept, is this the council tax money?
Jo Farrar
This is the council tax money.
Chair
Right, so it is not that the Government are giving them more money, it is that—
Jo Farrar
They are giving them access to that money.
Chair
We have to be very careful. Councils are being given permission to raise council tax. It is not money from the Department. Can we just be clear, is that £9.4 million the precept, the council tax, or is it—
Jo Farrar
No. It is a range of funding.
Chair
Just to be clear. The £9.4 million is central from the Department.
Jo Farrar
No, some of it is through the precept. Some of it is because we gave an extra £2 billion in the Budget in 2017.
Chair
Yes. We know there is money. This is not a different pot of money that you are talking about; this is mostly council tax precept.
Jo Farrar
Not mostly the council tax precept. Less than half is the council tax precept. There is also the improved better care fund, the money through the—
Chair
So these are all funds that we have already looked at.
Gillian Keegan
Maybe I could ask, Ms Farrar, are you comfortable that there is sustainability to shape the market, when you have a 41% differential in the fees that a self-funder pays and the fees that somebody who comes through the council pays?
Jo Farrar
It is quite difficult to compare self-funders, because self-funders will chose a level of provision and they will chose a different type of provision.
Gillian Keegan
I do not think that is often the case. I have personal experience of this. My grandmother was a self-funder until about five weeks before she died and she then went on the council thing. It was exactly the same service. There were only two self-funders in her home and it was exactly the same service. There was no different choice, it was just a matter of whether you had the cash or could sell a house to provide the cash. So I do not think that is necessarily true. Do you think that is sustainable?
Jo Farrar
Sorry?
Gillian Keegan
The differential between self-funded and council payment, which is below the benchmark cost of care in many cases: do you think that is sustainable?
Jo Farrar
What we have done, besides—
Gillian Keegan
That is normally a yes or no.
Jo Farrar
I have talked to you about the money that we have put into the Budget. What we have seen with local government is that since 2010-11 the funding has been quite consistent, right up until 2016-17.
Gillian Keegan
I am not asking about that. I am asking about a model that has two different prices for effectively the same service, with a 41% differential. Do you think that is sustainable?
Sir Chris Wormald
I think—a couple of things about that. The price differential, which the CMA points towards, some of that—bluntly, we do not know yet, because we have not completed the work—will be a “reasonable” price differential. You would expect a local authority buying in bulk to beat a spot price for an individual. There are certainly some cases where people are buying additional services, over and above what the local authority would pay for.
Gillian Keegan
Possibly, but I don’t think that is what is happening at the base level. There is cross-subsidisation, let’s be honest.
Sir Chris Wormald
Which I do not deny, but it won’t be the full 41%; there will be an element within that. The CMA report that that comes out of and I think we are responding to in early March, points particularly—there is a lot in this—towards the transparency of the market for self-funders. It is very difficult to get information about costs and it is an individual decision frequently taken at a point of distress, so there are definitely some big issues about how that market works that we want to look at.
Gillian Keegan
I would suggest that how the councils—
Sir Chris Wormald
Sorry. I was going to come to your sustainability question.
Gillian Keegan
No—I would suggest that how the councils are shaping the market is by paying less than the benchmark for the council funding. That is shaping the other side of the market, which is twofold: the price for self-funders and how many self-funders you have to get in, if you have the choice, to cross-subsidise the other part of the business. That is probably shaping the market.
Sir Chris Wormald
A couple of things. On the specific of the benchmark price, it is a benchmark price set by providers. Our guidance is that people should have regard to it. We do not suggest that people should necessarily pay the benchmark, as I was saying.
Chair
So you are saying that providers are trying to charge too much.
Sir Chris Wormald
No. I am just saying that it is a number that they put out as a benchmark price. Our guidance suggests—
Chair
What is the alternative number?
Sir Chris Wormald
We don’t have an alternative number. We suggest that local authorities should have regard to that number—that is, they should look at it—but it is then for local authorities to set the price.
Gillian Keegan
But then they don’t have the cash to have regard to it. They might be regarding it while looking in their pockets and not finding anything to regard it with.
Sir Chris Wormald
Of course, local authorities always have to balance what they want to do with what is affordable. I was going to say that I think we agree with the fundamental of your question. Clearly, the CMA has pointed to some quite significant problems in how the market works that we will want to look at. I would break your question around sustainability going forward into two. We have not seen anything as yet that suggests that the way this market is structured is not sustainable. Indeed, we have actually seen an increase over the past seven years in the number of organisations providing domiciliary care, and a stable number of nursing and care home bids.
Gillian Keegan
I accept that domiciliary care is slightly different from a business-model perspective as a provider. Is having a stable supply on the residential care side keeping up with demand? I thought that we were getting increasing numbers.
Sir Chris Wormald
I will go back to my previous answer. What has happened is that the number of care home bids has gone down slightly and the number of nursing home bids has gone up slightly. Again, it depends what you mean by demand. If it is demand in the sense of what councils were providing for in 2010, we are clearly not meeting that number—the numbers have gone down. If it is demand in the sense of keeping up with statutory responsibilities under the Care Act, yes. I will come back to my first answer on your sustainability question. We do accept that there are big challenges in the funding structure and the market going forward, and things will have to be done differently. Do we expect it to be exactly as it is now in five years’ time? No, we don’t, and that is the work we are doing around the Green Paper.
Gillian Keegan
I would say that the cross-subsidisation is probably not sustainable at the levels that it is at and you are not on a path to change it, but I would like to move on to another—
Chair
I think it is worth bringing Mr Garrod in. Mr Garrod, can you give an example of how you or a member of your association have dealt with this benchmark rate? How realistic do you think that is? Do you think that the private providers are putting their benchmark too high, or is that a realistic rate?
Glen Garrod
Thank you. There is some evidence that in the domiciliary care market there is a level of segmentation between organisations that will accept only private funding and those that will take a mixture.
Chair
But what do you think about this benchmark figure in particular?
Glen Garrod
This is the UKHCA rate that you are referring to. My colleague in Gloucestershire pays £26 an hour, my colleague in Oxfordshire pays £22, I pay £16.80 and there are colleagues at less than £14. In the main, those are sustainable figures because, in different parts of the country, the labour costs are very different. A national benchline can only be a guide, because in some places, it would genuinely be more expensive than we would need. Having said that, however, it is very important that what goes around that unit price is also considered. Are you paying upfront? Are you guaranteeing levels of income to those providers? Have you organised the providers in such a way that they can cluster for better effect, or are they operating in a very competitive market where they are each individually bidding for service? If you can organise, particularly around that, you are more likely to have a secure and sustainable supply of service.
Gillian Keegan
Can I just ask about security and sustainability? The only way that you could really, intellectually, do that is if you imagined that there was no self-funding at all—so there is no cross-subsidisation. Would your comments still stand?
Glen Garrod
In the domiciliary care market? Yes.
Gillian Keegan
I accept that that is a little simpler.
Glen Garrod
In the residential care market, we have a tried and tested vehicle that was derived by LaingBuisson around setting up what is a usual cost to pay. One of the big drivers of that is your capital costs. The standard rate for LaingBuisson is 12%. Some systems do not need to pay above 6%, which has a material effect on the unit price, because of land values and capital values. What you have to pay in Surrey—
Gillian Keegan
So are you saying that in cheaper places, it could be sustainable?
Glen Garrod
Yes.
Gillian Keegan
Without any self-funded cross-subsidisation?
Glen Garrod
Yes, but then you have to ask questions about your size. Are you a 30-bedded unit or an 80-bedded unit? There are material differences. But that is almost too simple a dichotomy: 20 years ago, the NHS did not typically buy much social care. Nowadays, in my sector, they are buying about 15% to 20% of beds.
Chair
Are they paying local authority rates? Where do they fit in?
Glen Garrod
This is where we would encourage joint commissioning, because from a provider perspective—
Chair
You could end up bidding against each other. Social services departments and the NHS could end up bidding against each other for the same bed.
Glen Garrod
Indeed so.
Chair
Does that happen?
Glen Garrod
In some parts of the country, it has.
Chair
Could you give an example of a region or an area where that has happened?
Glen Garrod
It depends. It is varied across the country, not necessarily by region but by local system, but—
Chair
Have you got an example of where it has happened?
Glen Garrod
We could supply those, but they are not in my head at the moment.
Chair
It would be very good if you could.
Gillian Keegan
Let us move on to another area that does not seem to be very sustainable, which is the workforce. You have unbelievable turnover rates. If I did the maths right, at any one time across the whole sector, there must be ongoing recruitment for about 400,000 people per year.
Chair
Does that ring true, Ms Allen?
Sharon Allen
It is true that we have people leaving at a rate of 900 a day and joining at a rate of 1,000 a day. We have a vacancy rate of 90,000 on any one day across the sector. It is important that the figures that you have been provided with come from the national minimum data set for social care, which my organisation collects and analyses on behalf of the Department. We talk about turnover, but in reality, we are probably talking about turnover and churn, because a lot of people move between employers within the sector, often for pay.
Gillian Keegan
Do you have any figures for how many are moving within the sector and how many are leaving the sector?
Sharon Allen
We know that 67% of people who start in a new role have come from within the sector. It is very difficult—
Gillian Keegan
That is 67%?
Sharon Allen
Yes. Providers find it difficult to gain exit interviews from people, so we have better data about where people are starting from.
Sir Chris Wormald
We should say, although that is clearly not as bad as if one third of people were leaving the sector every year, that two thirds of that 30% are recycled is still a problem. That is still not what you would want to see as a pattern.
Gillian Keegan
What is the average time that they stay in the organisations? Have you looked at that?
Sharon Allen
Yes. People who leave tend to leave quite quickly.
Gillian Keegan
What is quite quickly?
Sharon Allen
Within the first 12 months. There is an issue about looking at what happens around induction and about the support people are given both in terms of information about the role they are coming into—
Gillian Keegan
It is not necessarily pay, is it? It is dissatisfaction, if it is within a year.
Sharon Allen
I would say it is both. There are massive issues about pay. We have just conducted a big—
Gillian Keegan
I agree, but I am just thinking about the driver—
Sharon Allen
It is not just about pay—it is absolutely not just about pay.
Gillian Keegan
The driver for normally leaving that quickly—
Sir Chris Wormald
When we survey why people are leaving—it is self-reported, so we do not know whether they always give the exact reason—pay is one of the reasons, but by no means the only one, and an awful lot of it, as Sharon says, appears to be around good employers. People doing values-based recruitment—they have good induction, CPD for their staff and all the things that classically good employers have—seem to have much lower turnover rates, I think it is fair to say, than some others. Is that fair, Sharon?
Sharon Allen
Well, if I can phrase it slightly differently, we did a piece of research that led to a report called “secrets of success” and we asked employers who had retention rates of 90% or thereabouts what it was they were doing that we could share with the sector.
Gillian Keegan
Were they in a domiciliary setting?
Sharon Allen
It was across all sectors and also included individual employers and people using direct payments or other funds to employ their own care and support teams. The things that Chris has just referred to were indeed the things that they said. What we need to be careful about is saying, “If they can do it, everybody can do it.” It is very different in different parts of the country.
Gillian Keegan
It depends on competition for labour and the price and labour rates within the area.
Sharon Allen
Exactly. And there are good employers doing all of those things who still struggle to recruit and retain a workforce.
Chair
Where are the hotspots for problems?
Sharon Allen
Where you would expect them to be: London and the south-east, the golden triangle in North Yorkshire and areas where there is very low unemployment and competition from other sectors.
Gillian Keegan
Can you clear up something for us? One of the councils that I spoke to cited what they thought the problem might be. Most of these jobs are minimum wage jobs, or certainly entry-level, which means there is a lot of competition among employees. The fact that people were not respecting pay and travel time or costs of travel was a big factor. If you are travelling to one place of work, staying there all day and coming back on public transport, that is one factor to look at. But if you are moving around from place to place, particularly in rural areas such as those I represent, that could be a massive cost. Doing that at minimum wage, or slightly above minimum wage, is surely having quite a big impact on choice of employment at that level.
Sharon Allen
Yes, I completely agree. I used to be an employer. I used to run a large voluntary sector social care and supported housing organisation providing a whole range of services. The challenge of who pays for travel time for people who support people in the community was an issue then and is an issue now. You are right. I think it is a source of national shame that we talk about this sector as a minimum wage workforce. It frustrates me intensely that people conflate low pay with low skill. It is the former and absolutely not the latter. While pay is not the only factor, it is certainly something that needs to be addressed. If we want to do something about pay, the place to start would be to at least look at parity between the social care workforce and the health workforce.
Chair
Any particular professional groups? Nurses are paid less in social care than in health, for instance.
Sharon Allen
I am talking about healthcare assistants on average earnings of £17,500, whereas social care workers on average earn £15,000. That is just pay. We are not looking at the total reward package. I am talking about registered managers who have a hugely responsible job and the parity, or lack of, with nurses and social workers.
Chair
What about pensions?
Sharon Allen
Well, exactly. It is, as you know, predominantly an independent sector market with small employers. Until the recent pension changes came in, many people working in the sector will not have had a pension. Even now that people are opting in or out, some people are choosing to opt out because they need the money to pay the rent and put food on the table.
Bim Afolami
You are right about pay. That is obviously part of it. Putting that to one side, what else do you think would make it a more attractive career? If we don’t compare it to the NHS, what about retail, for example?
Sharon Allen
I think we’ve got a good story to tell; we are just not telling it, unfortunately.
Bim Afolami
This is your chance.
Sharon Allen
I was about to—
Bim Afolami
Even though I am sure the Chair will cut you off if you take too long.
Sharon Allen
I will be quick. We have just completed a consultation exercise with the sector on running a national recruitment campaign on social care. Unfortunately, if you do not have personal contact with social care through either family members or someone you know working in the sector—if all you hear about it is through “Panorama” or certain newspapers—you will just think it is all going to hell in a handcart. That is not so. When it goes wrong, of course that is dreadful for the people it goes wrong for, but let us not forget that 81% of services are rated good or excellent by the regulator. When social care is at its best, it transforms people’s lives. Is that story out there enough? No, it is not.
Bim Afolami
So you basically think it is a macro PR problem, in addition to pay and the various other things. You think that is the big issue.
Sharon Allen
I definitely think we need to change the narrative about what social care is, about the career opportunities there are for people and about the fulfilment that there is. Money is not the only thing that motivates people. It is important—
Bim Afolami
You are speaking to politicians—we agree. The only thing I would say about that is that, as we have already heard, it is very variable. You talk about career progression, but it depends who you are working for and what part of the country you are in, as I am sure you would agree. I suppose it is that bit that we are interested in.
Sharon Allen
Can I use myself as an example? I started off many years ago working as a social work assistant for my local authority in Derby. If you had told me then that one day I would be chief executive of Skills for Care, I wouldn’t even have known what a chief executive was. I was lucky. Someone saw some potential and I was supported, and I went and got my social work qualification and had done other things and—blah, blah—here I am. I am just one example. I could find you many people who started off as volunteers or frontline care and support workers who have moved up. It is also important to say that career progression is not just about vertical progression. Sometimes people want to move but they want to continue providing direct care and support, because that is what really fires them up. We have amazing opportunities in this sector, because we work with such a wide range of people, as you know—not just older people, but working-age adults with a whole range of care and support needs in all sorts of different settings—but the story is not out there yet.
Gillian Keegan
It is not only the story, though, is it? The turnover rates are stark. They speak for themselves, with or without the story. You then have the recruitment challenge, which is where the story is required, although it is much cheaper to retain than to recruit continuously. To feel valued as an employee, you need to be trained in the skills to do the job so that you are confident to do the job, you need to feel valuable enough to train and be professionally developed, and obviously you need to work with decent people and be paid a fair wage. I do not know how many people your organisation trains, but I think you have £14 per person per year. I imagine you do not spread it out in that way, but surely, with £14 per person per year, it is very difficult to provide professional development opportunities.
Sharon Allen
We do not actually provide the training. We are not a training organisation; we are the leadership and workforce development organisation. That £14 per worker goes on a range of initiatives around recruitment and retention, leadership development—
Gillian Keegan
So who pays? Does each provider pay?
Sharon Allen
Providers pay training providers to train their staff. We disburse a fund on behalf of the Department called the workforce development fund. About half of that £14 goes directly out to the sector to support employers to support their colleagues to gain qualifications and training.
Gillian Keegan
So they get £7 per person per year.
Sir Chris Wormald
Just to be clear, the primary responsibility for training staff—just like in any sector—is with the employer. This is what we do on top of that.
Chair
We understand that, but as Ms Keegan has highlighted, this is a low-skilled, low-paid sector, so one of the obvious questions is: what is the incentive for an employer to train someone up? Surely, Ms Allen’s organisation was set up to try to drive up standards and incentivise employers to do this.
Sir Chris Wormald
Yes. In terms of the incentive, you put your finger on it: employers who invest in their workforce and have much higher retention rates have a much cheaper business model, just like in any other sector of the economy, so there should be an incentive to be a good employer and train your staff.
Gillian Keegan
There is no way they can turn those words into action. They have a large amount of their workforce churning continuously, and they have pay challenges and investment challenges. Training means costs—not just the cost of training itself, but the cost of somebody being out for however many days. You are saying words that cannot be implemented.
Sir Chris Wormald
No, I do not think that is true. There are employers out there, as Sharon said, who are doing these things and who see the benefits.
Chair
How many employers?
Gillian Keegan
What percentage?
Sharon Allen
Sorry?
Chair
Can you give us an example of what a good employer is doing and tell us how common that is across the sector?
Sharon Allen
I think it would be career-limiting for me to start naming employers. I am not prepared to do that.
Chair
Can you give us a percentage?
Sharon Allen
I would point you to the CQC ratings: 81% are good or outstanding. They can only be good or outstanding if—
Chair
But that is as providers. What about as employers? What about developing their staff in the way Sir Chris Wormald has highlighted? He has painted a positive picture of good employers doing a great job, but the margins are small.
Sharon Allen
They are, and that is part of the problem.
Chair
They might keep their staff a little bit longer if they give them a bit of training, but what is the incentive to get them trained up to earn more money? Are there examples of employers who are doing that?
Sharon Allen
There are. Tomorrow night, we will be hosting the annual Accolades awards ceremony, which celebrates the best—
Chair
But back to Ms Keegan’s question. What are the percentages, roughly? I am not expecting you to have the precise percentages, but is it half the sector that is doing a good job? Is it 10%?
Sir Chris Wormald
No, sorry: here we do come back—
Chair
I am asking Ms Allen. Perhaps you could answer, Ms Allen, and then we can come to you, Sir Chris.
Sharon Allen
I am afraid I can’t give you an answer to that. What I can tell you is that about 48% of the current workforce have a level 2 qualification or above. That has not really shifted very much.
Chair
Over what period of time?
Sharon Allen
About the last seven years. Employers do say, “What if I invest in my workforce and they leave?” That is a concern, but of course the answer is: “What if you don’t and they stay?” We need to support people to skill up the workforce. Again, if I can use my own experience as an employer, I run an organisation that employs 1,200 staff. We invested very heavily in our workforce because we knew that that was the way to achieve the skills and ensure that we had a skilled and competent workforce who could provide high-quality care, but I was operating on a turnover of £33 million at a margin of less than 1%. That makes it incredibly difficult.
Gillian Keegan
I think we get that; that is why we have identified these challenges. But I suggest that you need to be thinking about how you solve them, because you cannot just say the words, hope that there are one or two examples and leave the rest of the market with a massive churn, not being attractive to people when the needs of the population are growing. You have to have more of an approach than that.
Chair
Sir Chris, how do you assess the accuracy?
Sir Chris Wormald
I take other things. The CQC ratings are very relevant. This is a people business; you cannot be a good or outstanding provider without having a good workforce. The fact that 81% are good or outstanding—
Chair
Sorry, but you can have a good workforce without having a trained workforce. There is a difference.
Gillian Keegan
Yes, and also one that does not want to stay.
Sir Chris Wormald
Nevertheless, the fact that the quality that CQC finds is actually going on is a relevant factor. However, as is set out in the NAO Report, we do recognise all the features that you are quoting. This is an area in which we are going to have to be more proactive going forward to solve the problems. That is why—for the first time, I think—we have been consulting on our future workforce plan not just for the NHS, but for social care at the same time. We will need to address all the issues that the NAO identifies and that you are raising in your questions. Let me try to set this out clearly: we are not saying that none of this is happening in the sector—as I say, standards in the sector remain very high—but we do recognise that there are enormous challenges coming towards us, for all the reasons you say, that will need to be dealt with in our workforce plan.
Gillian Keegan
There are others who have solved this problem. Again, you have a fragmented supply base and an employee base that is relatively low-paid and relatively low-skilled—or you want to develop their skills to professionalise them. That is obviously what you are trying to do. There are other industries that have this. The CITB, for example, uses that kind of approach so that people aren’t worried about skills. There are other approaches to this; you can’t just look to the good ones.
Sir Chris Wormald
All those things are indeed relevant. We are, of course, talking about a huge sector. It is easy to forget, but a million people choose to work in this sector, and it is therefore very difficult to move at pace.
Gillian Keegan
It is, but it’s also too big to fail.
Sir Chris Wormald
Absolutely, which is why we are taking the steps we are around the consultation and the Green Paper. We recognise exactly the challenges that you are raising. I come back, however, to the fact that, as measured by the CQC, what we see is really quite high standards in the sector. As I have said, there are challenges that go with a very disaggregated sector, but also advantages. It is not the case that these things are necessarily solved by centralisation, partly for the reasons—
Chair
I want to bring in Sir Amyas Morse briefly.
Sir Amyas Morse
I felt we travelled past a little bit quickly some of what Sharon Allen was saying. I just want to understand whether your organisation has enough money to do its job properly. As I listened to your numbers, it seemed to me that that whittled down to something like £5 per person, so I just need you to finish that off. I’m sorry we did not get a chance to hear it clearly from you.
Sharon Allen
I think your Report talks about the impact of the activity we undertake and makes the point that it is somewhat limited because of the amount of funding available to us to do it. If we had more, we could certainly do more.
Sir Amyas Morse
So how much more would you like?
Sir Chris Wormald
This is a new role for the National Audit Office—broker!
Sharon Allen
I hadn’t thought anybody might ask me that question, so I do not have an answer. What I will do is go back to the point about parity with our NHS colleagues. You might want to take as a starting point the investment that goes into Health Education England. I am not asking for anything like that, because I know that part of it goes into training, for example, junior doctors. However, something that was more parallel would be welcome.
Gillian Keegan
Wasn’t there at some point the idea of requiring providers to publish the amount of training that their staff undertake?
Sharon Allen
It is not something that they are required to publicise, but it is something that the CQC look at when they go in and measure.
Gillian Keegan
So they have to keep the data—
Sharon Allen
Absolutely.
Gillian Keegan
But not make it transparent or not show it to anyone.
Sharon Allen
They share it with the regulator, and I am sure that when local authorities go in and do their contract monitoring for those organisations that they are commissioning from, they also look at what training people are providing for their staff. I just want to go back to your point about the comparator of the CITB, because I think one of the things we need to think about is what levers are available to us in this sector. Not only is it a very fragmented sector, but very little is mandated. You cannot work in the construction industry or be a provider without registering with the CITB and paying for a licence. That is not so in this sector; there is very little that people have to do. So one of the questions I think it would be interesting to explore is what impact bringing regulation to the workforce would have, maybe starting with registered managers and giving them parity of esteem with other regulated professions like social workers, OTs and nurses.
Gillian Keegan
I think the question is, do you want to solve this or not?
Sharon Allen
I do—very much.
Gillian Keegan
Sir Chris?
Sir Chris Wormald
As I have said, we recognise the challenges going forward and we know we need to come forward with proposals to meet them. Exactly what the things that would make the difference are, however, is not straightforward. There is of course the type of thing we have just been discussing. There are of course questions about which professions should be regulated and which should not. We have those debates within the health service. We also have those debates within social care. I would merely observe that regulation of individual professionals in the way we do it in the health service is very expensive.
Chair
I can see you shifting in your seat.
Sir Chris Wormald
It costs about £120 per person.
Chair
I think what Ms Keegan’s really driven home is that it is about a different paradigm, isn’t it? If you pay people as cheap as chips, you do not get a skilled workforce and you have a high turnover, and all those issues. We are trying to get to what your long-term strategy is. We understand that as permanent secretary you can hardly make the commitment here and now that you will suddenly increase funding for Skills for Care or increase the pay overnight for all these staff, but shouldn’t your long-term vision be that there is a better-qualified sector that will be caring for you, me and the rest of us in the years to come?
Sir Chris Wormald
Yes. We want—
Chair
You have a vested interest, Sir Chris. You are young yet, but you will be coming down the line. [Interruption.] Yes—perhaps permanent secretaries can self-fund.
Sir Chris Wormald
I do not think that there is any disagreement among anyone here that the kind of things that Sharon has set out about a higher skilled and a much higher valued workforce are what everybody wants to see. I cannot say that some of the specific things that we have just been discussing are the answer to that.
Gillian Keegan
No, but you have to come up with the answer.
Sir Chris Wormald
Yes and, as I say, these are questions that the Government are looking at and have plans to come forward with—
Chair
It is now all in your Department.
Sir Chris Wormald
Yes, which is important. That is why the Government have committed to a workforce strategy in this area, and to a Green Paper. As I say, though, a number of these questions are quite nuanced. If you wish to professionally regulate more in the social care sector, that would clearly take cash out of other areas, and we need to debate those things.
Chair
Clearly there are always choices, but we are here to talk about the social care sector.
Gillian Keegan
I assume that your Green Paper will look at funding models as well.
Sir Chris Wormald
Yes, of course.
Gillian Keegan
At the moment, cash is being taken at local authority level, because there is no demand management.
Chair
You mentioned the Green Paper. From what you are saying, it will be based on the same amount of funding for social care.
Sir Chris Wormald
No, that is not what I have said. Juliet might want to say a little more, but there is obviously a debate that has been going on for quite some time about, first, what the right level of funding is in social care—
Chair
We know about the debate.
Sir Chris Wormald
Well, that debate has not been resolved.
Chair
You said categorically, “No, it’s not.”
Sir Chris Wormald
Those are questions we are looking at, but it is not simply a question of what the right level of public investment is. Part of the debate is what sort of level individuals should take, what families should do, what the state should do. Those are the—
Chair
Absolutely, so you are looking at that.
Juliet Chua
As the permanent secretary said, there are essentially a set of long-standing questions in this area about what a more sustainable settlement looks like for social care for the long term. It is a debate that has run—
Chair
For too long.
Juliet Chua
It has run across successive Governments, and the questions are about what a fair reform package is, what the right model looks like for social care in the future, and how to pay for it. Within Government, we are working with a range of experts—both Sir Andrew Dilnot and Kate Barker, who were the authors of the two most recent big pieces of work in this area. We will be bringing forward the Green Paper in the summer.
Chair
We recognise that there is a funding issue as well as a skills issue, but we are looking today at the skills in the workforce.
Anne Marie Morris
Clearly, Sir Chris, one of the key things that we need to understand is what the total cost of the need is, but how are you going to work out the cost if you cannot identify the total need? Let me explain. I live in a rural area, where an awful lot of the care is provided either by neighbours and family, the voluntary sector or—worse—people do not get the care they need, and we find people, usually ladies, in very isolated villages who have been dead for some while. Until you can determine the need, how on earth can you set the budget?
Sir Chris Wormald
There is no exact answer to that question, because beyond the statutory level of provision set out in the Care Act, there isn’t—
Anne Marie Morris
Don’t you think you need to look at it, despite the statute?
Sir Chris Wormald
It is about what your aspirations for the care system are. As with any other bit of public expenditure, there is no exact way of pricing exactly what it should be.