Written evidence submitted by Care England (WBR0012)
Care England, a registered charity, is the leading representative body for independent care services in England. Membership includes organisations of varying types and sizes, amongst them single care homes, small local groups, national providers and not-for-profit voluntary organisations and associations. Between them they provide a variety of services for older people and those with long term conditions, learning disabilities or mental health problems.
Care England appreciates the valuable work which the Health and Social Care Select Committee is doing to highlight the current pressures within the adult social care system. COVID-19 represents an unprecedented threat to the future sustainability of the sector and the support it provides to some of society’s most vulnerable people. Moreover, Care England wants to move the discussions forward by focussing on the positive contribution that social care makes to society as well as the resource and financing issues the sector faces.
The adult social care workforce is the frontline and needs the same access to resources as colleagues in the NHS in order to cope with the additional demands upon it.
Professor Martin Green, Chief Executive of Care England, would be willing to give oral evidence at future Committee meetings for this inquiry.
How resilient was the NHS and social care workforce under pre-COVID-19 operating conditions, and how might that resilience be strengthened in the future?
The adult social care workforce is our biggest resource. Before the pandemic it faced many adverse trends including absenteeism, recruitment, retention and turnover. COVID-19 has made some of these issues even more acute in the short term. Out of all of the hardship which has stemmed from COVID-19 there needs to be a positive trend towards professionalisation and reward in the adult social care sector.
Whilst the workforce is resilient it is only as resilient as the funding and support behind it hence the need for adequate long-term support for the sector. For too long, an increasing cohort of adult social care service users have been supported through a smaller pot of government funding. In turn, this has inevitable consequences for the nature of some employment opportunities within the sector. The number of older people and working-age adults requiring care is increasing rapidly, and public funding is not only not keeping pace, but has declined in real terms by 13 per cent between 2009/10 and 2015/16.
It is well documented that prior to COVID-19 the adult social care sector was overwhelmingly underfunded. Including, how its ability to operate had been critically affected by cuts to local authority funding. Ultimately, such cuts have been passed onto adult social care providers, which inevitably has some impact upon their own workforce and HR policies. Adequate and sustainable funding is therefore fundamentally intertwined with the future strengthening of the adult social care workforce. The care home market has suffered from underfunding for many years and was not in a robust position when it entered the COVID-19 pandemic. In May 2020, the Care Quality Commission spoke of their concerns about this:
“The people that the sector care for – primarily older people, often with underlying conditions – have made adult social care uniquely vulnerable to COVID-19, but this was a sector under pressure even before the pandemic. It is having a significant impact on the financial viability of adult social care services. Our Market Oversight report to the CQC Board in March 2020 highlighted the financial fragility of adult social care. We said then that, in the absence of mitigating action, any further shocks to the labour market would be expected to increase the existing level of market fragility, place more pressure on local authority finances and possible increase unmet care needs. The troubling financial reality for some providers is that they may now face a shortfall in people using their services due to increased deaths and not being able to admit new admissions.”
These concerns expressed by the Government’s own agency, are reflected not just within the concerns that are being increasingly raised to Care England by local and national care home operators, but also within Care England’s own detailed investigations.
It is also important to note that analysis by the Health Foundation prior to COVID-19 showed that there would be a social care funding gap of £4.4bn in England in 2023/24 even prior to COVID-19.
Other studies suggest an even larger funding gap. For example, continued levels of poor funding have manifested themselves in a potential funding gap of almost £6.5 billion by 2025 for local services. As evidenced in the LGA Budget Submission, having lost nearly £15 billion in central government funding in the last decade, many councils continue to face significant challenges when trying to set budgets this year and protect services from further cutbacks. After a reduction in the funding gap in 2020/21, LGA analysis shows that rising cost pressures and unprecedented demand for services - in particular adult and children’s social care and homelessness support - will see the funding gap facing councils in England rise again from 2021/22 before it reaches almost £6.5 billion by 2025.
The Low Pay Commission:
Wage costs are a large part of the adult social care sectors overall cost base given that the nature of care work is extremely labour intensive. For example, of those services questioned for Hft’s 2019 Sector Pulse Check, 95% cited rising wage bills as the main pressure point. Government policy in relation to wages has had some part to play in resilience or lack of prior to the COVID-19 pandemic.
For too long, the Low Pay Commission’s recommendations in relation to wages have not been matched by adequate government funding to allow the adult social care sector to implement such recommendations in a sustainable manner. This has, in fact, led to an array of negative effects, including how it has led to some social care providers having to decrease wage differentials and in turn their capacity to reward their most experienced staff. Thus, the unnuanced nature of the National Living Wage’s delivery cannot persist. In addition, the importance of such considerations are even more acute given the financial burden which COVID-19 has imposed upon the sector.
The King’s Fund concurs saying that: “In order to meet the national living wage commitments, hard-pressed social care providers have had to hold down the overall pay bill in other ways. An increasing proportion of the workforce is now paid at or around that minimum level and the pay differential between care workers with less than 1 year of experience and those with more than 20 years of experience has reduced to just £0.15 an hour.” Therefore, we implore this government to listen to the Low Pay Commission’s own guidance and recognise its role “in the sectors which Government itself funds – social care and childcare – sufficient funding is necessary to meet the cost of the rising NLW.”
Care England wholly supports the adult social care workforce being rewarded for supporting some of society’s most vulnerable, and that good and fair wages remain a lynchpin in the future sustainability of the adult social care sector. Given the sector’s contribution it is surely incumbent upon the Government to implement a funding system which allows this to become a reality and at the same time ensures the financial sustainability of adult social care providers.
Such funding realities also intertwine with a plethora of other factors relating to the resilience of the workforce. For example, insufficient funding has meant that the adult social care sector has been unable to compete in terms of the terms and conditions it offers to adult social care providers.
Public and government discourse:
However, resources are only one part of what led to the adult social care workforce’s fragility. For too long, care work has not been seen for the skilled work that it truly is. This has been compounded by the fact that governments of all stripes have neglected the initiation of those policies necessary to support the sector. We believe that such actions have ultimately played into the public discourse surrounding the nature of adult social care work.
Sad though it is to receive recognition through disaster, the coronavirus pandemic has brought to light the essential role of adult social care. Moving beyond lockdown, it is essential to craft a new approach, one that ensures that vulnerable people are not abandoned by the NHS and can benefit from a system of support in which health and social care act in a coordinated fashion focussed around the person and are financed adequately and appropriately. Whilst changes in rhetoric must be accompanied by long term reforms and sustainable funding models which the sector has been calling for.
What has the impact of the COVID-19 pandemic been on resilience, levels of workforce stress, and burnout across the NHS and social care sectors?
From the outset the adult social care workforce has gone above and beyond its duties. In many instances staff have moved on site and sacrificed a great deal of their personal lives. They have taken their responsibilities seriously often without the due respect and recognition that has been given to other front-line staff. Care staff have and remain at the front line of the UK’s interactions with COVID-19.
COVID’s spread has in many parts of the country been concentrated in hospitals and care homes. Such realities have inevitably and continue to impact the morale of adult social care staff.
Adult social care staff have taken the place of relatives and loved ones, they have been with residents throughout the pandemic through thick and thin including helping residents isolate in their bedrooms, at the bedside of dying residents and keeping the show on the road. They have felt bereft and grief stricken when residents have died and concerned for their own safety owing to a lack of testing. The physical and mental strain is unprecedented.
Adult social care staff have also had to prove adaptable to the changing needs of service users as a result of the COVID-19 pandemic. For example, due to the withdrawal of community NHS support, adult social care staff had to fulfil the many of the tasks previously fulfilled by NHS colleagues. However, their ability to do so has only accentuated their professionalism and ability to adapt during unprecedented circumstances. Such changes in the tasks fulfilled by adult social care staff inevitably impact the morale amongst staff.
The implications of COVID-19 upon absenteeism levels has inevitably impacted the morale of staff. Rising absenteeism levels has often meant that particular staff have had to pick up the slack and work additional hours in the place of other. Again, we believe that this is indicative of the professionalism which staff have shown during the COVID-19 pandemic.
Stress has also been compounded by the introduction of new working practices, including infection control procedures. At one point during the pandemic, guidance surrounding things like PPE changed on what felt like an almost daily basis. Such frequent changes inevitably lead to increased demands upon the adult social care sector.
Care staff have had to incur increased levels of risk as a result of COVID-19. In some parts of the United Kingdom, care staff have been rewarded through their national government providing a bonus to adult social care staff, for example, Wales. However, in England this has not been replicated.
Adult social care was let down by the NHS. If we are able to find anything positive out of this betrayal it is the upskilling of care staff who have risen to the challenge. Moving on it will be interesting to see whether the role of a care worker will reflect these changes and also the status of the role in direct comparison with their colleagues in the NHS.
What is the current scale of workforce burnout across NHS and social care? How does it manifest, how is it assessed, and what are its causes and contributing factors? To what extent are NHS and care staff able to balance their working and personal lives?
Many providers have sought to look after their staff as a top priority. They are well aware of the impact on mental health. For example, Care England has heard countless examples of adult social care providers taking steps to support their workforces. Including, the creation of 24 hour hotlines support social care staff.
Supporting the mental wellbeing of residents in light of their decreased interactions with family members has been very challenging work falling entirely to the adult social care workforce. Similarly increasing support for individuals with particularly complex needs has been difficult, for example a higher staffing ratio for those residents who have to self isolate in their bedrooms particularly those with learning disabilities or dementia.
The range of activities provided by charities and communities groups has also significantly fallen, and in turn, care staff have, and will continue to, step up to the mark in providing such activities to their residents.
Many staff were not able to take leave during the height of the pandemic and had to work long shifts. Over the last months, many care staff have also accrued significant levels of holiday. In turn, this will lead to substantial levels of backfill staffing being required – something which also has the potential to increase staffing costs in the immediate future. The threat of the High Court judgement on Sleep Ins is hanging over the sector; the back pay would be quite simply crippling. While the risk of a second spike within the community as we return to a ‘new normal’ also has the potential once again drive up overall staffing costs.
However, the impact of underfunding is not only evident in a physical sense, but also, underfunding and the focus for social care providers on achieving financial sustainability means that managers often don’t have the time nor headspace to think about workforce strategies. Care home managers are often confronted with the goal of ‘keeping their heads above water’, therefore, decreasing the amount of time which they have to invest in focusing upon other key issues such as the care workforce. This has been particularly evident during the COVID-19 crisis.
What are the impacts of workforce burnout on service delivery, staff, patients and service users across the NHS and social care sectors?
What long term projections for the future health and social care workforce are available, and how many more staff are required so that burnout and pressure on the frontline are reduced? To what extent are staff establishments in line with current and future resilience requirements?
The withdrawal of the Randox testing has caused a new level of upset and uncertainty amongst providers and their staff. Routine testing should have enabled staffing levels to return to normal and less reliance on agency staff; however until testing is fully embedded in the system this is not the case. Conversely widespread testing and test and trace system might also result in finding more staff have the virus who are asymptomatic and therefore need to self isolate.
The sector is bemused as to why DHSC has agreed that CQC inspectors, and some healthcare professionals, are to return to work in care homes without the need for either regular testing or PPE. This contradicts all the infection control measures that care homes have been painstakingly putting in place and does nothing to instil the confidence of residents, relatives or providers.
Key in overcoming workforce shortages is the implementation of an effective routine testing system. This will help to provide confidence to the workforce, but also, those who are considering a career in adult social care.
To what extent are there sufficient numbers of NHS and social care professionals in training for service and resilience planning? On what basis are decisions made about the supply and demand for professionals in training?
The adult social care sector has and continues to experience insufficient supply of workers. In particular, this is seen in terms of the vacancy rates which we continue to see in the sector. Skills for Care’s data stated that “8% of roles in the adult social care sector were vacant. This represents an average of approximately 122,000 vacancies at any one time.”
However, the necessary levels of supply are also intertwined with the high levels of staff turnover within the sector. Skills for Care’s most recent data found that turnover rates stood at 30% in 2018/19 for residential care workers.
Care England fears that the insufficient supply of care workers may become even more acute in the context of the UK leaving the European Union and the implementation of the new ‘points based immigration system.’ Currently, there is little means for junior care workers to enter the country under the new system. Given that it is due for implementation in January 2021, there is a risk that it may occur at the very moment when the sectors workforce needs are most acute in nature. In turn, there is a need for some thought to be given to the role which transition approaches may play for frontline sectors like adult social care.
Below Care England lays out some of those areas where we believe training for adult social care could be improved:
Early years recruitment:
Central to fulfilling this aspiration of producing and sustainable and valued care workforce is that we increase overall supply through the creation of an education and training system.
Part of this includes the introductions of a raft of reforms that support the workforce training and development structures which are already in place. These reforms span the school’s system, universities, graduate schemes and colleges. Care England believes that such reforms would also be of some importance in overcoming the fact that recruitment from younger age groups remains one underutilised pipeline of recruitment in the adult social care sector.
For example, a Work Foundations report found that only a third of new social care apprentices were between 16 and 25. Such a context has arisen as a result of a plethora of reasons, including that there appears to be a stigma around working in care which is preventing young people from applying for roles, which is perhaps a consequence of a lack of awareness and education around the career paths available within care.
Social care should play a larger role in the overall curriculum, this would solve two purposes. Firstly, it would help to break down the historical trend of the public in fact being largely unaware of social cares purpose and regular conflation with the NHS.
Secondly, greater awareness of social care in schools would help to break down the stigma attached to it which often dissuades younger people from going into social care related roles. At a recent careers event, young social carers explained the negative feedback which they had originally received when informing friends that they were planning to do so. This included the archaic perception that it merely involved the fulfilment of personal care. Care England believes that such notions can only be overridden by effective steps being taken from the very early stages of schooling.
This role is already somewhat fulfilled by Skills for Care’s ‘I care…Ambassadors’. They are care workers who inspire and motivate people to understand more about working in social care. Ambassadors visit schools, colleges and Jobcentres and run a range of careers activities, such as presentations and mentoring. However, we believe that this scheme needs to be further developed if we are to truly meet the future vacancies of the adult social care sector.
The need for such a policy has been compounded by the governments recent immigration changes and their suggestion that the social care sector should make greater use of the UK labour force. However, to do so we need a more thorough and widespread campaign around changing attitudes to social care.
Care England is of the view that the number of nurses who carry out a placement in a nursing home environment is currently not sufficient. This is despite the fact that student nurses have the opportunity to be placed in both the adult social care and health sectors. However, currently placements in care homes are perceived by many student nurses as a ‘back up’ and generally not appealing. This is again indicative of the general lack of parity of esteem which the health and social care sectors are held in.
Care England is of the view that if increasing numbers of nurses were to carry out placements in care homes that this would have a plethora of positive effects, including, an increasing recognition amongst the nursing population of the difficulties faced by the social care sector. Secondly, it could help to enhance integration by forging links between the health and adult social care sectors at the start of people’s careers. Whilst such a trend may also help to deal with the nursing shortages which we currently see within the adult social care sector. Overall, such a move would be of advantage to both the health and social care systems given their wholly interlinked fortunes.
What further measures will be required to tackle and mitigate the causes of workforce stress and burnout, and what should be put in place to achieve parity for the social care workforce?
Ultimately, during this time of crisis, social care providers should be given the necessary resources to allow them to focus solely upon providing care and support to some of society’s most vulnerable, as opposed to having to engage in a piecemeal manner with local authorities and CCGs. Maintaining the financial sustainability of social care providers is, in fact, of fundamental importance in maintaining the capacity of the integrated health and care system and the resilience of the adult social care workforce.
The current workforce shortages in adult social care are multifaceted in nature, they include those pressures which have emerged as a direct result of the COVID-19 pandemic. However, alongside this sits those existing workforce pressures which were an issue within adult social care prior to the COVID-19 pandemic. Future government policy must take account of the increasing burden which COVID-19 has placed upon the adult social care workforce and the sector as a whole. Short term measures and building upon those systems which have arisen as a result of COVID-19 are of particular pertinence in increasing the attractiveness of the adult social care sector in the short to medium terms, including, testing and PPE. The adult social care sector has inevitably experienced extremely high levels of sickness and absenteeism as a result of COVID-19.
Long standing issues for the adult social care sector will persist despite COVID-19 and it is in turn incumbent upon us to adapt to the new realities of society to create solutions for these issues. For example, how do we attract those people who have become unemployed as a result of the economic implications of COVID-19 against a backdrop of negative publicity around care homes and ageism? Similarly, turnover has been a long-standing issue within adult social care and we in turn need to continue to think about how we overcome such issues.
Maintaining both the attractiveness and size of the adult social care workforce is fundamentally intertwined with the issue of PPE, there needs to be sufficient PPE for staff to feel confident. Public Health England (PHE) and the Department of Health and Social Care (DHSC) have released 40 iterations and updates of PPE related guidance, in turn, causing confusion. The primary issue has been that the guidance released to date has not provided consistent messaging around the use of PPE so that social care providers are clear about when to use PPE and what type of PPE to use, nor has the guidance been consistently co-produced therefore omitting the very real concerns being felt on the front-line. The fragmented guidance has manifested itself in contradictory messaging being issued at both a national and local level; Care England continues to receive feedback from members stating that their Local Authorities, or Clinical Commissioning Groups (CCGs), are issuing fragmented guidance from that of central government.
Care England would be willing to give oral evidence to the Committee.
Professor Martin Green OBE