The Views of Practitioners on Care Act Easements during the Covid-19 Pandemic

Abstract

The easements of the Care Act 2014, permitted by the Coronavirus Act 2020, were in place in very few English local authorities and then only for a short time, but they still rippled across the wider social care workforce. This paper reports findings from interviews with social workers in ten non-easement authorities and with other professionals in easement and non-easement authorities to explore their understandings of easements and their reflections on their use and impact on practice. The interview data are set in the context of a wider study that explored decision-making about the adoption of easements in local authorities. Frontline practitioners (N = 30) confirmed confusion about easements and suspicion that they were a retrograde step in people’s entitlements to care and support. These views were also set in a context of lack of pandemic preparedness in social care and reflections that the care system was already fragile after a sustained period of reductions to local authority budgets and rising need. Both a robust care infrastructure was needed, as well as better crisis or disaster preparedness and planning.

Keywords:

• care act
• covid-19
• easements
• practitioners

Introduction

As the Covid-19 pandemic unfolded in the United Kingdom (UK) in 2020 the Government passed emergency legislation. The Coronavirus Act 2020 gave the Government new powers over multiple activities. Relevant to adult social care practice in England, Section 15 and Schedule 12 enabled the easement of certain duties imposed on English local authorities (LAs) under the Care Act 2014. Perhaps most significant, the LAs’ duty to meet al.l eligible needs in relation to adults in their area was replaced with a power to meet these needs. Accompanying Guidance from the Department of Health and Social Care (DHSC, 2020 and updated in June 2021 [DHSC, 2021a] and withdrawn July 2021) explained how LAs were allowed to reduce or change activities typically undertaken by social workers, such as assessments, care planning and, in certain instances where LAs adopted the easements, they could decide not to meet needs that would otherwise be met, if by doing so they would not violate human rights.

The Guidance also stated that easements were only to be applied when a LA was experiencing a significant rise in demand and a depletion of its workforce. Four levels or ‘Stages’ were defined. Stage One was ‘business as usual’ while Stage Two covered existing flexibilities already allowed under the Care Act 2014. Stage Three gave LAs permission to suspend certain activities, including Care Act assessments and reviews, as well as the requirement to offer a choice of care home. Stage Four allowed the full-scale prioritisation of care and support, meaning LAs could reduce an individual’s care and support package to meet more urgent and acute needs of others. These provisions of the Coronavirus Act took effect on 31 March 2020, eight days after the UK entered a period of social distancing referred to as ‘lockdown’, and they expired on 16 July 2021. However, during this period only eight of the 151 LAs declared that they were using these at Stages Three and Four. Most only did so for a very brief period (ranging from one week to three months) and only two used them at Stage Four (Baginsky, Thomas, and Manthorpe 2022).

The data for this article were collected as part of a larger study on the operationalisation of easements. In addition to the data reported here, data were collected from specialists in the care sector who had views on the introduction of easements (Baginsky, Thomas, and Manthorpe 2022), senior managers in five LAs that used easements (Baginsky, Thomas, and Manthorpe 2023a) and from 16 comparable LAs that had chosen not to do so (Baginsky, Thomas, and Manthorpe 2023b). Other studies have examined specific aspects of easements such as the impact on carers for those with dementia (Price et al. 2022) and on the impact on statutory obligations (McHale and Noszlopy 2021). Beyond easements there have been several explorations of practice during the first period of the pandemic in the UK. Some explored changes to work locations and communications, with social workers being the main professional group to have largely moved to home working at the start of the pandemic (McFadden et al. 2021). Another study investigated social work activity in adult safeguarding which was not affected by the easement legislative changes but saw new patterns of demand amid declining resources (Fernandez et al. 2020). Other national commentors also placed reactions to the pandemic in the wider context of pre-existing problems in the adult social care sector (Curry et al. 2023), a subject that was covered extensively in the interviews conducted in the other parts of this study referenced above. Both these interviews and the work of Curry and colleagues linked reductions in LA budgets in the previous decade and the destabilisation of the care market, leading to unmet need on a major scale. Combined with other structural and systemic factors this was thought to have both restricted the ability of the sector to respond to the pandemic and limited national understandings of and linkages to the sector.

However, to the best of our knowledge the impact of easements on those working closely with social work teams in the Care Act ‘space’ has not been addressed, so not to do so would have missed important crossovers at practice level. Across most of England there have been voluntary sector groups that have focussed on social care and support over many years, some pre-dating local authority social work. Currently many provide information, advice and advocacy, with some providing services through a contract with a LA including undertaking delegated Care Act activities such as assessments (see Fernandez et al. 2020). They often play a key networking role in their local communities. Like LAs, established voluntary sector groups have responsibilities at times of civic crisis. As McGarvey, Goodall, and Stuart (2021) noted ‘There are clear and established mechanisms, legislative duties, processes, and procedures which govern how local areas should respond to emergencies’. At a strategic level, LAs and voluntary sector groups have roles under the Civil Contingencies Act 2004, the Community Resilience Development Framework and Local Resilience Forums. However, McGarvey, Goodall, and Stuart (2021) found the engagement of the statutory bodies with the local voluntary sector was variable during the pandemic, although it was sometimes better if relationships had been forged through previous experience of joint working over events such as localised floods or disasters. Other studies of voluntary sector groups during the pandemic included both national surveys and case study analyses (King et al. 2022). Generally, the large surveys reported positive operational relationships with statutory agencies such as LAs during this time. More joint working was reported, particularly during the pandemic’s early stages. While there were exceptions, collaborations included new ways of receiving and taking referrals about people’s needs for care and support.

This article reports and discusses a set of interviews conducted in a later stage in the larger study described above (Baginsky, Thomas, and Manthorpe 2022, 2023a, 2023b) to provide perspectives from the frontline of practice about their opinions of easements in the context of their working experiences during the pandemic.

Methods

By the time even the earlier stages of the wider study started all the LAs that had adopted easements had ceased to use them. While senior staff were generally positive about engaging in our study, the criticism they had encountered from some quarters on introducing easements had added to the challenges of the early months of the pandemic (Baginsky, Thomas, and Manthorpe 2022). A consequence of this appeared to be a reluctance to permit us to interview their frontline staff, although it must be acknowledged that such staff were also reported to be extremely busy. This also meant that our original intention to contact service users who had been directly impacted by easements through their social workers or others was also not possible. As a result we were only able to interview social workers in LAs that did not use easements and these data are the focus of this article. In one of these LAs a senior manager who had been interviewed earlier suggested that it would be equally useful to speak to Occupational Therapy (OT) staff and we were able to do this in two local authorities where we were interviewing social workers. However, we were able to recruit representatives of advocacy or support organisations in both easement and non-easement LAs. These were identified by internet searches and recommendations from other interview participants and our advisory group. Sixty-seven organisations were approached, and 10 participants agreed to speak on behalf of their organisations. The organisations were given a £50 voucher as a token of appreciation and all participants were offered certificates for participating in research that could be used to provide evidence of continuing professional development.

We interviewed nine social workers from four LAs and held a group discussion with nine social workers in another LA. Two OTs were interviewed, one from an authority that had used easements and another from one that had not (see Table 1 for details). Ten individuals from the voluntary sector across two LAs - one easement and one non-easement - were also interviewed and brief details are also recorded in Table 1. All interviews and the discussion group were conducted over Microsoft Teams or Zoom and lasted between 30 and 60 min. All but one of the interviews were digitally recorded. In addition to a core set of questions on their experiences during the first year of the pandemic, the semi-structured interviews also explored areas specific to their service users or area of expertise. Interview transcripts were analysed using a thematic content approach based on the Framework Approach developed by Ritchie and Lewis (2003). After the research team had familiarized themselves with the data, transcripts were coded, and themes and subthemes were identified. The research team was female, with backgrounds in social work research and social care work.

Table 1. Identifiers for interviewees.

Code	LA Code	Participants	Use of easements
SW-7	NE7	Social worker	Non-easement
SW-14	NE14	Social worker	Non-easement
SWA-11	NE11	Social worker	Non-easement
SWB-11	NE11	Social worker	Non-easement
SWC-11	NE11	Social worker	Non-easement
OT-11	NE11	Occupational therapist	Non-easement
SWA-9	NE9	Social worker	Non-easement
SWB-9	NE9	Social worker	Non-easement
SWC-9	NE9	Social worker	Non-easement
SWD-9	NE9	Social worker	Non-easement
OT-9	NE9	Occupation therapist	Non-easement
SW-13	NE13	9 social workers	Non-easement
Code	LA code	Participant	Use of easements
Org-1	E1	Advocacy service and charity	Easement
OrgA-2	E2	Advocacy service	Easement
OrgB-2	E2	Provider and information and advice service	Easement
Org-4	E4	Information and advice service	Easement
Org-6	E6	Information and advice service	Easement
Org-7	E7	Charity	Easement
OrgA-9	NE9	Local provider	Non-easement
OrgB-9	NE9	Local provider	Non-easement
OrgA-13	NE13	Local provider	Non-easement
OrgB-13	NE13	Local provider	Non-easement

E: easement authority; N: non-easement authority

In Table 1 each code has a prefix of ‘SW’, ‘OT’ or ‘Org’ to differentiate between social workers, occupational therapists and people working for local organisations. Where we interviewed more than one professional in a local authority area, we have indicated this on the prefix. The code ends with the local authority identifier. It also contains the participant’s occupation, whether they worked in a LA which used easements or not and the region where the LA is located.

Ethical permission for the study was received from (to be inserted when peer review process completed).

Findings

The findings discussed below cover participants’ awareness and views on Care Act easements and their views on changes to professional practice during the pandemic.

Practitioners Awareness and Views of Care Act easements

Local authority Staff

Although they were all in non-easement LAs, all the social workers and OTs were aware of easements and had attended various webinars and forums, although they were not always clear about what easements involved. In some cases they conflated easements with the ‘discharge to assess’ (efforts to clear hospital beds by postponing assessments until patients were discharged) policy and others thought that they were the same as remote assessments. There were also those who mistakenly thought that easements were being used in their LAs and, in one case, that they were responsible for the delay in conducting financial assessments:

We were using easements in cases …where it was safe for us to complete the proportionate [assessments] or reduce the certain telephone [calls] and using more… because the people were more alert, more able to tell us what it’s like. (SWC-11)

Another social worker had received training from their LA about the Stages, including the differences between Stages Two and Three, and had then considered Stage Two ‘flexibilities’ as formal easements.

There was no mention in the interviews of any preparation for practice shifts that might be required during the pandemic having been made in advance of the lockdown. One social worker said it felt the crisis arrived ‘without warning’ (SW-14). This might explain why some practitioners recognised that that easements might have been useful if the workforce had been too depleted to meet high demand on services. With hindsight they thought that the decision taken by their managers not to invoke them had been the right one. There were those who had been concerned that easements would undermine the Equality Act (2010) and European Convention on Human Rights (1953). But it was the practical consequences that caused more unease. The fear was that by deprioritising cases at one point in time, pressures would not only build on their caseloads that would be difficult to manage later on, but that there would be immediate consequences for general practitioners (family doctors) and hospitals.

Staff in the Other Organisations

Those working in advocacy and support organisations had been aware of easements irrespective of whether they were in an easement area or not. Many had reservations about the measures, even if they sympathised with the reasons behind their introduction. One person who did not sympathise was a chief executive of a voluntary agency. She had taken part in a national campaign to revoke the measures, sharing petitions with their clients and signing letters to MPs. Her fear, and those of some others, was that easements would send a message to disabled and older people that they did not matter and that the processes around them could become a blueprint for future emergencies.

Those who worked in authorities where easements had been introduced said that communication coming from the LAs had not always been good. One organisation that conducted assessments on behalf of the LA was not told that easements were in place until weeks after they had been introduced and, elsewhere, one agency was never told, despite the working closely with the LA. However, in another easement area, an organisation had gone on to be involved in various aspects including reviewing shortened assessment forms. Running though the interviews were references to the link between the pressures that easements were designed to address and the pre-COVID state of social care, indicating that the measures were viewed within the context of prior challenges facing adult social care. In some areas it had become so fragile that there were concerns that it may not have withstood the additional demands created by the pandemic:

‘[The easements] made me really nervous … I’m very passionate about people getting the right support and care they need. (Before Covid) I often see adults with a learning disability going three or four years without a social care review and developing health issues which are not investigated … So I’m acutely aware as well of how my colleagues in social care are under lots of pressure and they can’t respond to everything, but with a whole different need, I just worried as soon as I could see that there might be a situation where people wouldn’t get the reviews and wouldn’t get the support they needed’ (OrgA-9)

Changes to Professional Practice March 2020 to July 2021

Local authority Staff

Social workers and OTs all worked in LAs using Stage Two ‘flexibilities’. They reported how disorientating the very early weeks of the pandemic had been and how they had been required to be extremely flexible in responding to demands. Most had moved from offices to working from homes, although the support or technology for that transition was not always optimal. As elsewhere, there had been a shortage of both personal protective equipment (PPE) and testing for the virus so attempting to address these difficulties had been prioritised. While social workers in emergency duty teams usually had access to testing, this was not always the case for those working in mental health teams who were continuing to visit some people at home. Some social workers referred to fractured communications and lack of responsiveness between departments. One social worker described a pervading sense of uncertainty during the early months of the first lockdown:

There was so much different guidance coming out and it was so confusing … Things were changing so rapidly, and just not having an overview from the government, and management higher up, I just think it was a bit of a shambles to be honest. Nobody really had a plan in place. (SWA-11)

However, participants described adapting quickly to an ever-changing work environment. Both social workers and OTs had moved to a seven or 14-day rota, working 12 h shifts to be available during weekends and evenings. Apart from those working in hospitals and in mental health teams, all had all undertaken ‘remote’ telephone or online assessments and reviews with what was described as ‘variable effectiveness’. There were instances where home care workers had asked for their clients to be assessed or visited by social workers in-person, but social workers had not been able to make face to face visits other than in emergencies.

Pressures on practitioners’ caseloads did not necessarily increase in the early weeks following the lockdown and this may explain why the conditions of Stages Three and Four of the easements were not met in the LAs where we interviewed practitioners. In the early stages of the pandemic demand was reported to have fluctuated and even deceased as people avoided social contact. Practitioners suggested that many people had lowered their expectations in relation to social care, both because of the perceived risk of contracting the virus and the desire not to burden services. Some noted that service users had been more difficult to contact during the pandemic and others pointed to a drop in safeguarding concerns, possibly reflecting the message to stay at home and social distance, and the cessation of inspections of care homes.

Staff in the Other Organisations

Those working in local organisations in easement and non-easement LAs had seen disruption to social care services, such as the closure of day and respite services. These were acknowledged to have had a huge impact on service users, their families and carers. A theme running through the interviews in organisations, in both easement and non-easement LAs, was concern that the assessments conducted at that time had led to reduced care packages. The fear was that judgements that service users appeared to be able to manage with less support could become the norm.

In one easement LA two organisations reported that assessments and reviews had taken longer to occur and there had been concerns that some people had not been re-assessed despite changes to their needs or increases in their caring responsibilities. Despite these reservations and concerns, those who were working in local organisations did not know of anyone who had been adversely affected by the easements. They identified cases where there had been changes to social care services, but they could not link them directly with the impact of easements:

There was the assessments and things like that which led to people’s packages being cut, but it wasn’t… you couldn’t say it was a direct result of the Care Act easements because they weren’t using that; it was just like I say, that cultural thing about health and social care. (Org-7)

Some organisations in the voluntary sector had found it harder to communicate with staff in LAs, including one case where there was a safeguarding concern. It was not clear why having more staff working at home made them harder to reach on the telephone, although in at least one instance an external organisation was not allowed to have social workers’ email addresses. However, there were also examples of how some of those interviewed had been able to establish closer working relationships. For example, improved collaboration between an external agency and a LA led to a blended support service for people with learning disabilities that allowed face-to-face contact and remote support:

We were able to change the whole service and deliver a new service and have it signed off within two weeks which, in my whole career, I've never seen anything move at speed like that … I would say that working with (the LA) in the pandemic I saw …a different way of doing thing … people were really, really listening and then responding…I really hope that we take that learning on, and we don’t revert back to services as they were. (OrgA-9)

Strengths and Limitations

LAs that had used easements and whose managers had participated in the study did not allow us access to their social workers and, as a result, this study is limited by missing the voice of practitioners working in easement LAs. It also means it was not possible to identify any service users who had been impacted by easements and their voice is also missing. It is also important to acknowledge that the research was conducted 10 to 12 months after any LA that had used easements had ceased to do so. Nevertheless the findings provide an important contribution to what is known about how frontline practitioners and external organisations understood and responded to easements, as well as how they had managed through the early months of the pandemic.

Discussion

Neither social workers or those working in local voluntary and advocacy organisations indicated any strong support for Care Act easements, even where they appreciated the rationale behind implementing imperfect but pragmatic measures during a crisis. At best the easements were seen as possibly necessary and, at worst, a further degradation of a struggling social care system and an insult to disabled and older people. They were introduced in haste into a situation for which the country was largely unprepared and where ‘actions (had) been slow and insufficient ….and (where) countries (had) done too little, too late to contain the epidemic’ (The Lancet, 2020). Practitioners contributing to this study were critical of the lack of planning which reflected other studies conducted in England including Nyashanu, Pfende, and Ekpenyong (2020) study of the views of health and social care workers, the findings of a scoping review conducted by Jones, Schnitzler, and Borgstrom (2022) and the views on senior managers interviewed in the wider study, of which this is a part. However the general lack of clarity about easements displayed by social workers may link with the wider deficit in knowledge of the duties under the Care Act 2014 which Jenkinson and Chamberlain (2019) identified prior to the pandemic or easements. The levels of understanding of the Act were not explored by the authors in interviews and to have done so may have added a deeper understanding of the response. However, in this instance it is perhaps not surprising that they may have had uncertainties around easements as they were in LAs that had decided against invoking them.

The participants’ observations on the apparent absence of preparations for social care and social work practice during a pandemic reflects what we have come to learn about national preparedness. The Exercise Cygnus Report (Public Health England 2016) was commissioned by the NHS and based on a simulated influenza pandemic. The Government’s response to this report was only made public after an intervention by the Information Commissioner’s Office in June 2021. The report had concluded that the UK’s level of preparation was ‘not sufficient to cope with the extreme demands of a severe pandemic that will have a nationwide impact across all sectors’. At the same time the DHSC was also required to release its briefing paper on Adult Social Care and Community Care (DHSC, 2021b) This briefing paper noted that Exercise Cygnus had identified a knowledge gap in the preparedness of community services, including both adult social care and community health care. Doctor Moosa Qureshi, who had fought for the Cygnus report to be released, described the DHSC briefing paper as inadequate and said it had ‘ignored the risk of infection spreading in care homes from those discharged from hospital’ (See Leigh Day 2021). Nevertheless once the pandemic was acknowledged practitioners worked very hard to maintain the best possible level of services under very different and challenging conditions. Banks et al. (2020), in their international research with social workers, focused on this ability to adapt when they argued for the inclusion of social workers in future national planning for emergencies. The sentiment goes well beyond social work and is reflected in countries around the world where, too often, health and social care were not prepared to face an emergency such as COVID-19 (Villa et al. 2020).

The speed with which easements were introduced and the pressures on services that were adjusting so rapidly to hybrid working and maintaining the rules of social distancing, amongst other things, possibly contributed to the confusion that participants expressed over easements. The guidance (DHSC, 2020) did not help to address this confusion. While the level of awareness that they existed was high, a clear understanding of what easements were was not always evident. Some practitioners equated easements and social distancing measures introduced at the start of the pandemic, while others thought the flexibilities that all LAs could use amounted to the use of easements. However, some of the practice changes that they described appeared very similar to those adopted in easement authorities which suggested that practice was sometimes remarkably fluid during the first few months of the pandemic. It also appeared that while the authorities that adopted easements had come in for considerable criticism from some quarters, others were doing much the same ‘under the radar’. Nevertheless it was clear that easements were viewed as potentially damaging. And while some working in both LAs and other agencies may have sympathised with the pressures facing their LAs, they did not want easements, or anything similar, to be the default response to future crises.

Conclusion

Practitioners and local organisations faced challenges throughout the pandemic which, in their view, could not be solved by ‘easing’ the Care Act. While the easements were not rejected entirely, there was significant scepticism and even fear of the consequences of their implementation. The confusion surrounding the measures raises the question of how easements can be evaluated as a pandemic response when there was inconsistent interpretation of the legislation and guidance. Flexibility, good working relationships, communication and planning were posited as aiding work with people accessing social care services by both LA practitioners and voluntary sector workers.

Acknowledgements

The authors thank all participants who shared their experiences with us and members of the study’s advisory group for their support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was funded by NIHR School of Social Care Research, but the views expressed are those of the authors and do not necessarily reflect those of the funder.

Notes on contributors

Emily Thomas

Emily Thomas is a Research Assistant in the Health and Social Care Workforce Research Unit. Email: [email protected]

Mary Baginsky

Mary Baginsky is Reader in Social Care in the Health and Social Care Workforce Research Unit. Correspondence to: Mary Baginsky NIHR Health and Social Care Research Unit, King’s College London, London, UK. Email: [email protected]

Jill Manthorpe

Jill Manthorpe is Professor Emerita of Social Work at King’s College London. Email: [email protected]