Written evidence submitted by Homecare Association
Homecare Association’s Response to the Public Accounts Committee’s inquiry into Access to Urgent and Emergency Care
People are living longer lives with more complex needs. The over 65s are the largest growth cohort in the UK population. For example, in England and Wales there are almost 11 million people aged 65 and over - 19% of the total population. In 10 years’ time, this will have increased to almost 13 million people or 22% of the population. A significant lack of resources and funding for social care services is preventing the sector from coping with this increased demand. In homecare, workforce shortages mean many providers simply cannot take on new clients, and some providers are unable to staff existing contracts and are left with no choice but to hand work back.
This lack of capacity in homecare is impacting urgent and emergency care. If hospital beds are occupied by people who no longer need to be there, new patients needing help cannot be admitted. This means that ambulances cannot transfer patients requiring admission to A&E and are also not available to respond to new emergencies. It also means that people requiring elective treatment cannot be admitted and waiting lists are currently over 7 million. Almost a quarter (24%) of delayed discharges from hospital are due to people waiting for homecare.
In the community, unmet need is high and rising. Councils have waiting lists for assessments, direct payments and care services of more than half a million. Over 1.6 million people need support with care at home and are unable to access it due to insufficient funding and workforce capacity.
Delayed discharges and the inefficient supply of homecare is the result of there being an alarming shortage of homecare workers, with the sector’s vacancy rate reaching a record high of 14.1% in October 2022, though by May 2023, it had fallen to 12.6%.
The ability to recruit and retain homecare workers is a significant constraint on the ability of providers to grow. Worryingly, in our latest research over half of providers (54%) reported that they are delivering less care than this time last year. This is despite almost three-quarters (74%) of providers stating that the demand for homecare had increased since the beginning of 2022.
Around two-thirds of providers (66%) considered recruitment to be harder, either somewhat or lot, compared to six months ago. Meanwhile, 87% thought recruitment was harder when contrasting with prior to the pandemic. Inadequate careworker pay was identified as the single greatest negative effect in recruitment and retention of staff, with 42% of providers identifying this an issue.
Too often the public sector including both local authority and NHS commissioners purchase care at below the rates needed to deliver quality, and undertake poor commissioning practices that can undermine the market. Low fee rates, zero-hours commissioning and models of purchase which fragment the volume of hours and offer no security of income making it challenging for providers to improve the pay, terms and conditions of employment for careworkers.
Homecare providers have also seen a significant increase in demand for hospital discharge services – nearly two-thirds (64%) suggested there has been a rise in the quantity of care packages for people who were being discharged from hospital. Furthermore, 71% felt that there is an added time pressure to ensure a care package is arranged.
We asked homecare providers about the experiencing of working with hospital discharge teams. More than half (56%) of homecare providers agreeing that more complex tasks were now being commissioned by the NHS.
They told us about the impact of the complexity of the cases and that some people are being discharged without adequate care packages.
“We have seen a big increase in patients being declared “medically fit”… and discharged WITHOUT adequate (or any) care in place. (We get a worrying number of calls from frantic relatives who have had a phone call to tell them [that] their loved one is being sent home - and they need to put care in place) Often, [they are] in a worst physical condition than when they were admitted.”
“We run a Discharge to Assess (in Somerset) service to allow patients to be discharged from hospital and our team work closely with them as a reablement service to get their independence/confidence back. However, the complexity of the patients means they are coming on to our services with ongoing care needs, which regrettably, due to the state of social care, [ends] up blocking the D2A service.”
Some homecare providers that were not currently offering discharge services, spoke of the challenges of working with discharge teams.
“Working with the hospital discharge team has proven to be far too difficult. Getting hold of the right person to discuss possible services that could ease their pressure is next to impossible. During conversations with staff on the discharge team, they do not shy away from the fact [that] they are severely understaffed, overworked and are just about coping with their current demand – but cannot help companies like us because they are not authorised to make such arrangements!.”
“We do take NHS-funded care packages on hospital discharge, but often, care assessments are not as accurate as they could be. Usually, they are offered to us as a single carer call and then they turn out to need two staff and we don't have enough staff to cover this. Most likely, this is due to assessments being carried out [in] a fully-equipped hospital ward and not in the front room of a [two]-bed terraced house.”
“The rates for hospital discharge remain the same as generic homecare, and packages are less predictable – [not] paid if discharge is delayed/higher risk of patients dying in shorter periods after discharge, so the work is higher risk. The rates are too low anyway to recruit effectively.”
Impact of the pressures on the health and care system
The impact of the pressures on the health and care system is being felt by those who need healthcare, with 85% of providers saying that the people they support were finding it more difficult to access healthcare than this time last year.
Just over half of providers (51%) either agreed or strongly agreed that avoidable hospital admissions have been more frequent than at any time before, with only 9% in disagreement. Meanwhile, around half agreed to some extent that more people to whom they provide homecare require hospital treatment than last year.
Integration of NHS, social care and community services can contribute to holistic preventative care. Joined up services help to identify individuals most a-risk and enable them to be treated in the community rather than in hospital settings. Good communication is essential to deliver this. Care and support practitioners should be included in Multi-Disciplinary Teams. The fact that a care and support practitioner may have a good knowledge of the person’s wishes, behaviour and any changes that they are experiencing might be invaluable in providing the right care. This relationship and knowledge is often not recognised. Care providers are not always included in MDT reviews at the moment, and may not have the outcomes of MDT meetings communicated to them.
Unmet need in the community
As highlighted earlier in the response, there is significant unmet need in the community. This unmet need for social care means that the most vulnerable patients – often elderly and living with multiple long-term conditions – are more likely to become ill and require care in the NHS.
Homecare can be key to preventing people’s conditions deteriorating, avoid putting unrealistic expectations on unpaid carers and reduce the risk of individuals needing more costly and resource intensive health and social care services in the future.
Investment in homecare, an not just discharge services, need to be seen as key to improving access to urgent and emergency care.
The Government should provide adequate funding needs to be provided by government to local authorities to enable them to pay a fair price for care, so that careworkers can receive wages equivalent to Band 3 healthcare assistants in the NHS with 2+ years’ experience. According to the Homecare Association’s Minimum Price for Homecare 2023-24, this would require an hourly fee rate of at least £28.44.
The practice of local authorities and the NHS purchasing homecare ‘by-the-minute’ must be ended, alternatively focusing on achieving the outcomes people want, enhanced by technology solutions.
The Government should develip a long-term workforce plan for adult social care which models future workforce requirements and seeks to diversify the types of roles available, as well as developing career structures. This should be aligned with NHS workforce planning to enable a joined-up workforce and to enhance the quality of care provided by both the NHS and social care.