CIH response to Health and Social Care Select Committee inquiry into Adult Social Care Reform: The cost of inaction

Analysis by the King’s Fund in 2023 estimated that delayed discharge from hospital resulted in direct costs to the NHS of £1.7 billion. Factoring in indirect costs, such as delays to elective operations, the estimate of potential savings from resolving delayed discharges would be around £7 billion.

Delayed discharge is not entirely due to delays in social care support. However, the scale of savings that could be released by timely discharge is significant and it would provide knock on benefits of addressing increases in hospital waiting times for treatment; a key milestone for the government’s mission to improve the NHS. The King’s Fund analysis points to the significance of housing within the overall picture of delay, being a growing factor in delays prior to the pandemic, and continuing since then.

Costs of social care provision for local social care authorities is extensive and an increasingly large proportion of overall expenditure (around 70 per cent). A recent report from the County Councils Network highlights the growth in the costs of social care services for people of working age, due to the increasing complexity of needs and conditions with which people are living. Without reform, this will reach £17 billion for working aged adults alone by 2030. There are also concerns across local authorities about the timeframe and resources to implement reforms appropriately. Suitable housing can provide help to address this, rather than only being considered in the context of if/when equity should be used to meet care costs.

Supported housing

Recent analysis of NHSE data by the National Housing Federation (NHF) found that the number of patients who had a hospital stay of more than 14 days and a delayed discharge due to housing related issues has nearly tripled since 2022 (an average of 53 patients per week in quarter one of 2022 compared to an average of 148 per week in the same quarter of 2024).

The impact is even more notable for discharge from acute mental hospitals where lack of supported housing was the biggest single reason for delayed discharge in May 2024, accounting for 19 per cent (6,609 days).

The NHF estimates that savings of between £20-50 million could have been accrued in 2022/23, should sufficient supported housing have been available for the 109,129 people who required it, compared to the cost to the NHS of about £56 million.

Supported housing, whether for older people or those with learning disabilities/autism, who require additional care, or for people previously homeless or those with addictions, is a critical part of the solution to help people live well and as independently as possible. It also prevents or reduces the demand for more formal costly social care, and enables the care that is required to be delivered safely. Nine in 10 residents have at least one health condition or disability whilst about half have three or more. But supported housing has demonstrated its value in terms of wellbeing for residents and in reduction of demand on and costs to public services such as health and social care. For example, a Local Government Association (LGA) report estimates that a supported accommodation scheme in Bradford helping people who are homeless or at risk of homelessness with intermediate care and support saves the NHS approximately £47,000 per person. A longitudinal study into the impact of housing with care by the ExtraCare Charitable Trust revealed that their model led to reductions on costs to the NHS and social care, and significant improvements in residents’ self-reported wellbeing.

Mainstream housing

In addition to supported housing, the condition and accessibility of existing homes can be a delaying factor in timely and successful discharge from hospital. Unsafe, non-decent homes are estimated to cost the NHS more than £1 billion, and social care a further £1.1 billion, plus £3.5 billion for family and friends providing unpaid care.

Since 2015, Disabled Facilities Grant (DFGs) has been included in the Better Care Fund, with a priority of delivering more effective hospital discharge. In 2016/17 DFGs received a large increase in funding (79 per cent) reflecting the rising demand for adaptations, the role of adaptations in supporting people to be successfully discharged from hospital, and the economic and social benefits from spending to save (reducing or preventing further increases in demand for health and care services). Delays to making timely adaptations increases the risks for older and disabled people and reduces their effectiveness.

Given the increase in older people’s households, including those living alone, and people living with long term limiting conditions, demand for DFGs will increase. Many middle-income households are unable to access DFGs, but still require support to identify trusted contractors to repair and adapt homes, with advice, information and support as identified in the Care Act 2014 (examples include the proposals for Good Homes Hubs).

The severe limitations on resources, and rising demand across both health and social care, mean that the focus remains on firefighting and searching for further savings without the time or resources to invest in services that prevent or reduce increasing needs.

The Care Act 2014 envisioned a partnership approach across local areas, including housing providers, to invest in services that maintained people’s independence, and that provided safe homes for those being cared for and their carers.

The current remit of Integrated Care Systems (ICS) includes a focus on prevention, reduction of health inequalities and better outcomes across health and care. This provides a positive framework for tackling issues across local communities, working with them and wider partners, including housing, to develop services that promote wellbeing and prevent ill-health. Partnerships are emerging around and within this structure but  broader joined up strategic partnerships across local places is more sporadic, following the loss of the proposed £300 million Housing Transformation Fund committed but not delivered in the last social care white paper which was intended to drive it forward. With the constraints on existing budgets across the board, supporting ICS’, councils and partners to take this strategic approach to planning future services will require additional funding, separate from the costs of implementing social care reforms. This should be utilised to facilitate data sharing and link up assessments and strategies (supported housing strategies, housing strategies, older people’s housing strategies, health and wellbeing strategies etc.), and to ensure these carry across to shape and inform Local Plans.

The reduction of local authority budgets has led to a backlog in the number of assessments, which is likely to lead to increased burdens falling on informal unpaid carers, and/or deterioration of the person’s condition and therefore ability to undertake tasks for themselves. The Nuffield Trust identified 400,000 on the waiting list for care assessments at March 2024, 78,000 of whom had been waiting more than six months. This does not take account of people with unmet needs who do not request assessments; Age UK estimate that around two million older people are living with unmet needs.

Increasing demand on family and friends for unpaid care has been linked to many reducing their work or leaving the workforce entirely, particularly those in their 40s or 50s, with consequent impacts for personal finances and their contributions to the wider economy. There are also increased costs where caring impacts on the carers’ physical and mental health. The 2021 Carers UK State of the Nation survey revealed that 25 per cent of carers reported their physical health was bad or very bad, and 30 per cent reporting bad or very bad mental health.

An earlier report from 2016 identified that carers’ key concerns about homes were the lack of space in the home (to live comfortably and/or to have space for others to stay and help with caring), the wait for adaptations, and disrepair of the home.

The County Council Network’s (CCN) report underlines that the impact for disabled people of that lack of care and support includes limitations on the everyday activities of life, meaning they are denied a ‘gloriously ordinary life’, more problems keeping well and healthy, and difficulties in participating in education or employment.

For the economy, there is the loss of revenue as disabled people in inappropriate housing are four times more likely to be unemployed than their non-disabled counterparts, are more likely to be in poverty, and more likely to move out of employment more often and into new employment less frequently than non-disabled people.  ‘Inappropriate and insufficient housing was highlighted repeatedly… as a key issue preventing optimal outcomes…’ (CCN, p30).

The NHS is a key focus of government’s priorities, with one of its five missions being to build an NHS fit for the future. CIH has welcomed the inclusion of increasing house building as a milestone in the priority to kickstart economic growth. Addressing social care is unfortunately absent in the missions and milestones. However, it is critical that there is an overarching framework that enables these priorities to be joined up, nationally and locally, with social care incorporated within that, alongside housing and health.

The development of a long-term housing strategy led by MHCLG provides an opportunity to link this up and ensure that it provides a framework to drive the development of the right homes in the right places, and investment in existing homes, that meets needs across housing, care and health for current and future populations. It should incentivise a similar strategic approach across local areas and within ICSs.

Government should develop a process for future spending reviews and budgets, that can identify where investment in one policy area can deliver demonstrable savings for others (such as supported housing for both health and care) to enable flexibility at the local level for more shared/pooled funding to support strategic planning.

The Nuffield Trust called for a narrative on caring as part of the national infrastructure. This echoes CIH’s call for a framework at national and local levels that supports a strategic and shared approach to developing and shaping local places, neighbourhoods and homes to meet local needs and priorities together, including:

More accessible and adaptable housing

• The number of homes that are accessible or easily adaptable are severely limited. However, 14.1 million people or 21 per cent of the UK’s population is disabled, including a significant increase in people of working age and children within that figure. In 2019-20, 53 per cent or 1 million households did not have the adaptations they needed in their homes. The most acute housing shortage is for people requiring wheelchair adapted homes; Habinteg Housing Association estimate that about 400,000 people requiring such housing are stuck in unsuitable homes.
• Research by LSE for Habinteg has demonstrated the long term financial benefits of wheelchair accessible housing - £67,000 over a ten year period for a household with a disabled child and £94,000 over the same period for a working aged disabled adult. This is due both to savings for public services, including health and care, and to revenue generation through people active in the workplace.
• Implementing the government’s previous commitment (made in July 2022) to introduce higher accessible and adaptable standards (the Building Regulations Part M4(2) standard) for all new homes without delay would be a critical step forward in enabling people to access homes that are safe, decent and support them and carers in daily living.

More supported housing

• Ongoing investment in supported housing via the Care and Support Specialist Housing Fund (CASSH), with set targets within overall housing targets, will drive more development of specialist housing. The recent report of the Older Persons Housing Taskforce recommends a target of 10 per cent for specialist housing for older people (in addition to the current target of 10 per cent for supported housing more broadly, within the Affordable Homes Programme).
• Investment in a national, ringfenced funding stream for housing-related support is necessary to boost the sustainability of existing and new supported housing schemes. A stable and consistent investment nationally and locally in the critical support services within specialist housing that provide invaluable help and support to maintain independent living is required.  The lack of funding for a core element of supported housing causes real difficulties for landlords and service providers and does not create a conducive environment in which to invest in new supported housing. A ringfenced funding stream is needed which should be at least equivalent to the last such investment programme of £1.6 billion for England (the figures of £1.58 billion for England and £2.05 billion for Great Britain were estimated in the evidence review for government in 2016). This should be separate to but sit alongside the local authorities’ funding for commissioning care services.

Visit the committee's website to find out more about the inquiry.

For more information on our response please contact Sarah Davis, senior policy and practice officer on sarah.davis@cih.org.