PROFESSOR LEE-ANN FENGE AND DR ANDY PULMAN, BOURNEMOUTH UNIVERSITY – WRITTEN EVIDENCE (ASC0023)

Professor Lee-Ann Fenge is Professor of Social Care at Bournemouth University, Director for the Centre for Seldom Heard Voices, and research lead for the National Centre for Post-qualifying Social Work (NCPQSW) at Bournemouth University. She is writing in her capacity as a researcher with a track record of research concerning the social care workforce. She has an interest in those individuals and groups who are marginalised and disadvantaged within society and whose needs are often overlooked. She is a registered social worker and has published extensively about the social care workforce, marginalised identities and safeguarding.

Dr Andy Pulman is a Post-Doctoral Researcher. His research interests include digital health, health inequalities and the use of technology to improve all aspects of health and social care. He is currently working on an NIHR study to generate insights into the challenges of building capacity to undertake social care research across the sector and the opportunities for building research engagement and capacity across HEIs and social care in Wessex.

Professor Fenge is available to provide further detail and give oral evidence as needed.

EXECUTIVE SUMMARY

  1. One of the fundamental challenges facing adult social care is that it is ‘invisible’ in comparison to the NHS. This is a complex issue which has long historical roots in terms of the way society defines medical versus social need, deserving and underserving groups, and the professional standing of those that work in health or social care. A move towards integrated health and social care provision provides an opportunity to raise the profile of the centrality of social care within society’s approach to promoting the wellbeing of all citizens.
  2. What are the key changes that need to be made to reduce the invisibility of adult social care: The lack of a robust evidence base about the value and efficacy of social care undermines how it is perceived in comparison to health care. This also limits its visibility as an essential component of a functional and sustainable integrated system of health and social care which is essential in promoting the wellbeing of citizens. Joined up health and social care research and practice is one way to profile the importance of social care within a more holistic understanding of health, wellbeing and integrated provision. Initial findings from our Clinical Research Network (CRN) Wessex study confirm previous research findings concerning a currently unbridged gap between the drive for social work/care to be more evidenced based and the ability of social work/care to enact this approach.  
  3. Putting co-production at the heart of care: Co-production should be put at the heart of social care in terms of personalised responses and co-produced research and development. The centrality of partnership and co-production with experts by experience across the lifecycle is essential to project the voices of those that receive social care support, and to engage the wider public in improved understanding of the aspirations and lived experiences of marginalised and invisible groups who receive social care support.
  4. Conversations about social care need to respond not only to present challenges but also future challenges posed by an ageing population. This includes recognition of diversity of experience: this can arise from different needs across the lifecourse; diversity of circumstances including those who self-fund, those who are reliant on state funded provision, and those who experience marginalisation and health/social care inequalities.
  5. The social care sector is a major national employer but the majority of the 1.58 million jobs that make up the social care workforce in England are not professionally regulated including the provision of front-line direct care (Skills for Care, 2017a). Recruitment into social care is an ongoing challenge, and this requires creative thinking not only about levels of pay, but more importantly how career structures, training and development opportunities can be used to create a sector where individuals can perceive that they have a lifelong career rather than just a job. Brexit and the COVID 19 pandemic have undoubtedly led to further stresses in the social care system around the retention, recruitment of the social care workforce, which in turn undermines the quality of care on offer to those reliant on social care support. A small-scale Bournemouth University funded research project at the start of the pandemic noted the many difficult impacts of the pandemic on a small group of locally based social care workers. These pressures undoubtedly added further to the pre-pandemic stresses of the job – negatively impacting the emotional wellbeing of the social care workforce which has historically been identified as a key element in staff burnout. These impacts will have been more widely felt in larger more populated regions of the country, particularly in areas where creating a dedicated team to deal only with COVID-19 positive service users would have been impossible.
  6. What are the key challenges that people who draw on care and support and carers will face in the future, which are not factored into current assumptions related to the social care system: Independent living and smart home technology will have increasing importance across social care as part of personalised and inclusive responses for disabled and older people to live their best lives. As part of this it is important that older and disabled people are involved in decision making and the development of high-quality evidence of the impact of technology on their lived experience.  Social care expertise around engaging seldom heard groups will be important to co-produce new solutions based on peoples’ experiences and a need to respond to issues of access and digital exclusion.

 

Lifting the Veil: Removing the invisibility of adult social care

  1. What are the key changes that need to be made to reduce the invisibility of adult social care? A move towards integrated health and social care provision provides an opportunity to raise the profile of social care. The NHS Long Term Plan (NHS England, 2019a) sets out key objectives over the next 10 years, including a commitment to improve the delivery of care outside hospital settings through integrated community-based provision, and social care is a key element of this. It is important that the voice of social care is recognised as a key partner that helps to shape and influence future integrated services and methods of working. The social care sector, the voices of its workforce and those who use its services are seldom heard in research and practice. We need to design integrated services in partnership with citizens and communities, particularly marginalised groups, and re-evaluate the worth of social care. There is a need to raise the funding, profile and status of social care for meaningful integration. Social care is well placed to provide a social justice lens within the wider integrated system to promote increased understanding of oppressive structures and practices. This includes consideration of societal narratives which can marginalise certain groups, organisational narratives which may highlight risks rather than strengths and professional narratives which reinforce stereotypes (Hundley et al. 2022). This offers an important counterbalance to medicalised view of need.
  2. What are the key changes that need to be made to reduce the invisibility of adult social care? An improved research evidence base into the efficacy of social care will help raise its profile and visibility. In the UK, health service research is viewed as a ‘core function’ planned through research and development (R&D) supported by organisational approaches to build research capacity development (RCD). In social care settings there is a lack of an established culture of research, alongside workforce and staffing issues, resulting in limited high-quality social care research taking place. Building health service research capacity in the UK is viewed as a ‘core function’ planned through research and development (R&D) which support an organisational approach to building research capacity development (RCD) (Whitworth et al. 2012). RCD requires the support and development of sustainable abilities and skills to enable individuals and organisations to perform high quality research. This suggests that a culture of research can be fostered by strong internal organisational infrastructure which supports individual career planning and skills development (Gee and Cooke, 2018).  There is currently a lack of a systematic approach to RCD across social care and a paucity of research to illuminate best practice. Social care needs to develop its own system and research infrastructure to develop understanding of what works and why (data and analytics to create new innovations), with improved pathways to impact demonstrating the value added of good social care (Geoghegan and Fenge, 2022). Indications from our CRN Wessex funded study highlight and confirm findings from other recent studies. In 2020, an NIHR Research Design Service consultation identified three main areas of challenge concerning designing and conducting social care research: (1) the complexity of social care organisations and funding - social care comprises multi-sector organisations that can go through frequent system changes and that work with severe budgetary limitations; (2) Research culture and research readiness - there is less of an infrastructure to support research cultures and research activity in social care compared to health care; (3) Opportunities to undertake and develop social care research - there are limited opportunities to commission social care research, priority-set and translate research for practice. Another recent study of social work/care staff within a large NHS Foundation Trust (Wakefield et al. 2021) showed a high rating on the relevance of research to professional development (73%) but a low level of actual involvement (10%) and low levels of confidence/knowledge across a range of research skills. Identified barriers included a lack of knowledge on where/how to begin, lack of evidence that it improved practice, the potential to threaten practice and low capacity and time.
  3. What does truly co-produced care look like for younger and for older people with differing challenges and needs? Have you got any good examples to share? Promoting the voice of ‘experts by experience’, including service users, carers and practitioners is an essential way of promoting the visibility of social care. The importance of developing healthy and sustainable communities through asset-based approaches to reduce health and social inequalities was highlighted in the Marmot Report (2010).  Engaging with service users, alongside work with local communities, is a key approach to responding to public health challenges. Participatory and collaborative research can co-create new knowledge which ‘is emancipatory, it leads not just to new practical knowledge, but to new abilities to create knowledge’ (Reason and Bradbury, 2008, p. 5). Research undertaken by the Centre for Seldom Heard Voices at Bournemouth University with a range of diverse communities illustrates how co-produced participatory research can lead to wider social impact and awareness of those that rely on social care. For example, the experiences of LGBTQ+ citizens, older male carers, young disabled people, and homeless people (Fenge, 2010; Hughes et al. 2017, Hodges et al. 2014, Fenge et al 2018). It is vital that social care practice and research is underpinned by strengths-based approaches that works in partnership with individuals and communities to achieve best outcomes for those who require social care support. 
  4.                     Social care is well placed to respond to the Social Care Institute Excellence (SCIE)’s research mindedness criteria (2012) which include being prepared to challenge inequality and oppression in all aspects of research. To achieve this, the voices of service users and participants from all fields must be included appropriately, for example, through peer models of research which provide ‘insider links’ into communities (Vaughn et al. 2018), and through inclusive participatory research methodologies, and such approaches sit comfortably with the strengths-based value base of social work and social care. A recent review indicated that investment in research capacity-building, and opportunities to exchange knowledge across researcher, practitioner, and user/carer organisations is required (Cyhlarova et al. 2020) to respond to the current challenges within social care.             
  5.                     What effect has the COVID-19 pandemic had on adult social care: As we focus on the future visibility of social care, it is vital to consider the standing of social care as an employment space, and the perceptions of the public concerning career routes in social care. Professionally regulated jobs (e.g., nurses, social workers) account for only 5% of the total workforce (Skills for Care, 2017a). Demand for social care services in England is growing exponentially, yet recruitment and retention of social care staff are long‐term endemic problems. Prior to Brexit and the COVID 19 pandemic, turnover rates in non‐professionally regulated direct care roles increased from 28.4% in 2012%–2013% to 33.8% in 2016–2017 (Skills for Care, 2017a) with vacancy rates hovering around 7% (Skills for Care, 2017a). These patterns persist despite the implementation of the National Living Wage which has increased wages in the lowest paid roles, indicating that “employers are struggling to find, recruit and retain suitable people to the sector” (ibid, p. 5). Evidence suggests that the combined impact of Brexit (Read and Fenge, 2018) and the COVID 19 pandemic has led to further challenges around the recruitment and retention of the social care workforce, which in turn exerts an adverse impact on the lives of those reliant on social care support. High levels of vacancies and staff turnover continued through the pandemic at on average 6.8% in 2020/21 - a staff vacancy rate equivalent to 105,000 vacancies (Skills for Care, 2021). In 2020/21 there was an estimated turnover rate of 28.5% and although 63% of this number remained within the sector this still means a net loss of around 152,000 staff (Skills for Care, 2021). Although turnover rates decreased during the pandemic, Skills for Care has received feedback from employers in the sector about staff and registered managers experiencing ‘burnout’ due to the pressures of the pandemic and that there is a risk of staff leaving as a result (Skills for Care, 2021). Indeed, many participants to the Skills for Care overview last year (2021) noted that recruitment and retention was now more difficult than before the pandemic. Staff turnover can have many negative organisational consequences (Hussein and Turnpenny, 2020) - an increased burden on long-term workers, the weakening of social support and informal networks in the workplace and most importantly a disruption in continuity and quality of care. In 2020 (prior to the COVID-19 pandemic), non-UK nationals represented 17 per cent of the social care workforce in England (Skills for Care, 2020). It is likely that the post-Brexit immigration system will result in on-going challenges that will be compounded by the impact of the COVID-19 pandemic on the social care sector (Turnpenny and Hussien, 2021).  In terms of the COVID-19 impact, our BU funded local research has noted how reablement staff have had to cope with the mental and physical effects of the pandemic and fears for their own health alongside rapid role change, the increasing use of technology and additional demands of infection control on their day to day role due to COVID-19 restrictions.
  6.                     What are the key challenges that people who draw on care and support and carers will face in the future, which are not factored into current assumptions related to the social care system: It is likely that digital and smart home technology will play an important role in providing personalised solutions for those who receive social care support in future. A recent report into smart home technology to support independent living has been launched at a special meeting of the All-Party-Parliamentary-Group for Assistive Technology (APPGAT) in the House of Lords (28/04/22) and was sponsored by Bournemouth University. The ‘Smarter Homes for Independent Living’ report explores how technology can help older and disabled people live more independently in their homes and outlines tangible actions for government and industry to help people take full advantage of technology and help people live better, for longer in their own home environment whilst reducing pressures on the NHS and social care system.  Social care expertise around engaging seldom heard groups will be important to co-produce new solutions based on peoples’ experiences and a need to respond to issues of access and digital exclusion.

 

References

Cyhlarova, E., Clark, M. and Knapp, M. 2020. Recruiting Participants for Adult Social Care Studies: Challenges and Mitigating Strategies, NIHR SSCR Methods Review 25, NIHR School for Social Care Research, London

 

Fenge, L. 2010. Striving towards Inclusive Research: An Example of Participatory Action Research with Older Lesbians and Gay Men, British Journal of Social Work, 40, 878-894

 

Fenge, L. Cutts, W. and Seagrave, J. 2018. Understanding homelessness through poetic inquiry: looking into the shadows, Social Work and Social Sciences Review, 19 (3), 119-133


Geoghegan, L. and Fenge, L. 2022 What social care research is and why it is important: Podcast. Available from:

https://www.emeraldgrouppublishing.com/podcast-what-social-care-research-and-why-it-important

 

Hodges, C.E.M., Fenge, L. and Cutts, W. 2014. Challenging Perceptions of Disability through Performance Poetry Methods: The "Seen but Seldom Heard" Project, Disability and Society, 29(7):1090-1103,

 

Hughes, M., McKay, J., Atkins, P., Warren, A. and Ryden, J., 2017. Chief cook and bottle washer: Life as an older male carer. Journal of Community Nursing, 31 (4), 63-66

 

Hundley, V., Richardson, P., Murphy, J., and Fenge, L. 2022. Working together in health and social care research. Available from:  https://www.councilofdeans.org.uk/2022/02/codhresearchmonth-2022-blog-working-together-in-health-and-social-care-research/

 

Hussein, S. and Turnpenny, A. 2020. Recruitment and retention of the social care workforce: longstanding and emerging challenges during the COVID-19 pandemic. Project Report. PSSRU, the University of Kent, Kent, UK.

Marmot, M.; Allen, J.; Goldblatt, P.; Boyce, T.; McNeish, D.; Grady, M.; Geddes, I. 2010. The Marmot review: Fairsociety, healthy lives. In The Strategic Review of Health Inequalities in England Post-2010; Institute of Health Equity: London, UK

 

NIHR Research Design Service Blog (2020). The RDS Model of Support for Social Care Research. Available from: https://www.rdsblog.org.uk/the-rds-model-of-support-for-social-care-research

 

Policy Connect. 2022. Smarter Homes for Independent Living: Putting People in Control of their Lives, All-Party Parliamentary group for Assistive Technology. Available from: https://www.policyconnect.org.uk/research/smarter-homes-independent-living

 

Read, R. and Fenge, L. 2018. What does Brexit mean for social care? Employers’ and managers’ perspectives., Health and Social Care in the Community https://doi.org/10.1111/hsc.12684

 

Reason, P. and Bradbury, H. 2008. The Sage Handbook of Action Research, Sage, London.

 

Skills for Care 2017a. The state of the adult social care sector and workforce in England, September 2017. Available from https://www.skillsforcare.org.uk/Document-library/NMDS-SC,-workforceintelligence-and-innovation/NMDS-SC/Regional-reports-2015/SFC-SWREGION-WEB.pdf

 

Skills for Care. 2020. Individual employers and the personal assistant workforce report, 2020. Leeds: Skills

for Care, Available from www.skillsforcare.org.uk/topics

 

Skills for Care. 2020. The State of the Adult Social Care Sector and Workforce in England. Available from: https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-2020.pdf

Skills for Care. 2021. The State of the Adult Social Care Sector and Workforce in England. Available from:
https://www.skillsforcare.org.uk/adult-social-care-workforce-data-old/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-State-of-the-Adult-Social-Care-Sector-and-Workforce-2021.pdf

Turnpenny, A. and Hussein, S., 2021. Migrant home care workers in the UK: a scoping review of outcomes and sustainability and implications in the context of Brexit. Journal of international migration and integration, pp.1-20.

 

Vaughn, L.M., Whetstone, C., Boards, A., Busch, M.D., Magnusson, M. and Määttä, S., 2018. Partnering with insiders: A review of peer models across community‐engaged research, education and social care. Health & social care in the community, 26(6), pp.769-786

 

Wakefield, J., Lavender, S., Nixon, K., Hornby, S., Dobel-Ober, D., Lambley-Burke, R., Spolander, G., Bonner, P., Mallen, C. and Campbell, P. 2021. Social Work and Social Care: Mapping Workforce Engagement, Relevance, Experience and Interest in Research. The British Journal of Social Work.

 

 

23 May 2022