RSE0019
Written evidence submitted by Centre for Care - University of Sheffield
This submission is provided by the Centre for Care (further information about the Centre is included at the end of this document). It responds to 3 areas identified in the call for evidence:
● Plans to coordinate and manage risk to the reforms;
● How to tackle low pay and support career development in the workforce;
● Revised plans for system reform published in April 2023.
1) Plans to coordinate and manage risk to the reforms
We agree with NAO’s analysis that DHSC ‘does not have an overall programme to manage and coordinate its ongoing reform activity in adult social care’. NAO also pointed to the lack of a ‘theory of change’ to guide implementation and evaluation. Without this we feel there is insufficient attention to the interaction effects, not only of the various new programmes, but also of how they are embedded within existing complex systems of health and care.
The policy mix: The NAO noted that DHSC had a poor understanding of the cumulative impact of the reforms on local authorities, and it is clear more work is needed on this. We also feel DHSC lacks adequate understanding of the policy mix within social care, and the interdependencies of reforms to funding, workforce, integration, unpaid carers, etc. In our recent book, Social Care in the UK’s Four Nations, we compare the adult social care systems of Scotland, England, Wales and Northern Ireland, and argue that if future social care policy reforms in any of the four are to achieve their goals, then it is important to think about this policy mix (Needham and Hall, 2023). This requires a holistic approach to ensure that goals are coherent, linked to the same overall aims and can be achieved simultaneously.
Two paradigms: Our analysis found that in social care the existing policy mix pulls reform efforts in conflicting directions: making the care system more formalised and centralised, and making the care system more informal and decentralised. Some care reforms (particularly integration with health and professionalising the workforce) seek to promote more standardisation, centralisation and formality within the care system, whereas others (particularly person-centred provision and investment in prevention) encourage more differentiation, localism and informality. Implementation of care reforms repeatedly gets stuck, or fails to achieve its goals, because policy makers do not acknowledge or engage with the tensions of calling for fluidity, differentiation, informality and co-production whilst also arguing for standardisation, regulation, formality and risk avoidance. This tension was clear in the Care Act 2014 (as well as in equivalent reform initiatives in other parts of the UK) and is partly to blame for the disappointing implementation of that Act.
2) How to tackle low pay and support career development in the workforce
The need for a long-term workforce strategy led by Government: We agree with NAO’s recommendation that DHSC should publish a long-term plan mapping its reform activity and the funding needed to achieve its intended outcomes. This should include a long-term workforce strategy for social care, comparable to the NHS workforce strategy, underpinned by the public investment needed to make it a reality. This should build on the work currently underway by Skills for Care to develop a 15-year strategy for the adult social care workforce.
Strategic workforce planning is crucial to enable the sector to respond and adapt to system shocks such as Brexit, the Covid-19 pandemic and the cost-of-living crisis. To date, a lack of strategic planning has had a deleterious impact on the workforce. No contingency plans were put in place to recruit more UK workers following Brexit, and there was a lack of support to address the impact of Covid-related absences among the care workforce during the pandemic. Long-term planning is urgently needed to tackle underlying recruitment and retention issues in social care and to reduce overreliance on international recruitment.
Pay: increasing care workers’ pay is crucial to tackling the workforce crisis. This must include extra funding for local government to spend on adult social care to ensure a pay increase for care workers does not put further unsustainable financial pressure on local authorities and care providers. Increases in the National Living Wage are welcome, but the implicit assumption that care work is worthy only of the lowest legally permissible pay should be challenged. This means emphasising the professional and skilled nature of care work and exploring ways of introducing pay progression that recognise specific skills and experience, and reward workers who gain promotions or qualifications.
Some care providers are implementing a banded payment system that reflects NHS pay scales; adopting this approach at a national level could have a significant positive impact on recruitment and retention. There is currently a large gap in pay between NHS and social care roles at similar levels (Holt et al., 2022).
Supporting career development: DHSC plans to support career development for the adult social care workforce, including a proposed Care workforce pathway, appear to have stalled. The aims of the pathway are laudable and include several important positive features:
● Acknowledgement of the growing complexity and value of care work and of the skills required: “we still have no universal career structure or clear articulation of the level of expertise and responsibility needed to deliver high-quality, personalised and increasingly complex care and support.”
● Opportunities for progression to more specialist roles that involve ‘hands-on’ care work as well as management roles. This type of work, rather than administrative or managerial responsibilities, has been shown to motivate many care workers to enter and remain in adult social care (Rubery et al., 2011; Stacey, 2011).
There are also some important weaknesses in the proposed approach:
● Lack of clarity about funding available for implementing the pathway; successful implementation will require investment. It will be essential to formulate and share long-term plans for funding arrangements with stakeholders, focusing on how implementation costs will be distributed between the state and care providers. The more senior roles proposed are welcome but must be rewarded by higher wages.
● Underpinning the proposed pathway is an assumption that providing more training will increase retention and help resolve workforce capacity issues; care providers providing good training are more successful at retaining their workers, but we should be wary of assuming a direct relationship exists. Employers that invest in training may be more attentive to the other needs of their staff and offer better working conditions and employee engagement. Workforce bodies and trade unions should be involved in development plans to maximise insight into how the pathway could improve workforce capacity.
● Implementing training requires financial resources and workforce capacity – releasing care workers from their regular duties to participate in training means others will be needed to cover this work. Professor Carol Atkinson advised the House of Commons Health and Social Care Committee in 2022 that care workers often struggle to participate in training: ‘The reality is that time and funding constraints make it difficult to access’.
● The emphasis in the proposed pathway on ‘values’ must not detract from a focus on the skills and knowledge needed, which can be learned. References to ‘values’ in the pathway include a proposal to establish “a universal set of values for the whole adult social care workforce.” This approach is common in social care but what it means in practice is often poorly defined (Manthorpe et al., 2017).
○ Some researchers argue a ‘universal’ values approach can undermine responsiveness to diversity of care needs and practices, and some disability studies scholars warn against overemphasising ‘emotional’ skills (Cartwright, 2015).
○ Differences in values have been observed between older and younger workers in care settings (Fisher, 2021).
○ There is evidence that, when used as a management tool, emotions and ‘values’ can have a deleterious impact on workers (Allard & Whitfield, 2023).
○ A pathway strongly focused on ‘values’ may divert attention from the structural and economic issues in the sector that are integral to the ongoing workforce crisis.
● Careful consideration needs to be given to whether any new framework should be mandatory. A voluntary roll-out across the sector could worsen some existing problems. Much care workforce ‘churn’ arises from workers moving between care providers (Skills for Care, 2023). Uneven roll-out of a new care pathway could exacerbate this.
3) Revised plans for system reform published in April 2023.
The decision to delay the implementation of the cap on care costs (from 2023 to 2025) needs to be understood in the context of previous delays to implementing the charging reforms set out originally in the Care Act 2014. The inclusion of a care cap in the Health and Care Act 2022 means this has now been legislated for twice. Lack of preparation for this (necessary preparatory work within DHSC and local authorities is not happening), with a General Election expected in 2025, mean this reform is unlikely to be implemented.
The reintroduction of the cap in 2022 should have been an opportunity to learn lessons about why the cap was abandoned in 2017. However, the previous failure has effectively been repeated. Key players in the sector (LGA, ADASS) supported the reforms but highlighted implementation tensions and funding pressures. These were cited by DHSC as the reason for abandonment, suggesting a poor learning culture in the department and poor attention to implementation in the policy design phase.
Local authority managers we interviewed in 2023 felt the charging reforms proposed in 2021 (including reducing prices for ‘self-funders’) were likely to destabilise a fragile provider market, and required large-scale recruitment of social workers to undertake the necessary assessments, which was unaffordable and unrealistic given social worker shortages. Areas with many self-funders were particularly concerned about the destabilising effects of these plans; our interviewees were also concerned that the reforms did nothing to support working age people with disabilities.
Although many of the social care reforms proposed in 2021 have been abandoned, CQC assurance of local authorities is going ahead. Research we have undertaken on behalf of West Midlands ADASS has found local authorities broadly welcome this, despite understandable nervousness in the context of worrying local authority finances (and issue of further Section 114 notices). Local government interviewees mostly felt the new CQC assurance process was improving the profile of social care, enhancing the focus on quality and the experiences of people using services, and allowing local authorities to showcase good practice. There were some concerns about new risks for the sector, including inherent reputational risks, some of which were considered manageable through preparation of staff and corporate ownership of the process. Further work needs to be done to address performance across the whole system, which links into (evolving) Integrated Care System assurance processes and broader system effectiveness.
References
Allard, C. and Whitfield, G.J. (2023) Guilt, care, and the ideal worker: Comparing guilt among working carers and care workers, Gender, Work & Organization.
Cartwright, L. (2015) ‘Affect’. In R. Adams, B. Reiss & D. Serlin (eds) Keywords for disability studies. (pp. 30-32). NYU Press.
Fisher, D. U. (2021) “You never know what you could walk into”: the perceptions and experiences of adult social care work for young adults in Teesside, North-East England. Doctoral Thesis, Teesside University, School of Social Sciences, Humanities and Law
Holt, A., Melley, J. and Burns, J. (2022) ‘Care workers paid £8,000 less than NHS equivalents in England - study’ BBC. https://www.bbc.co.uk/news/uk-64025830
House of Commons Health and Social Care Committee Report (2022) Workforce: recruitment, training and retention in health and social care.
Manthorpe, J., Harris, J., Samsi, K. and Moriarty, J. (2017) Doing, being and becoming a valued care worker: user and family carer views, Ethics and Social Welfare, 11(1), pp.79-91.
Needham, C. and Hall, P. (2023) Social Care in the UK’s Four Nations, Bristol: Bristol University Press.
Needham, C. and Burn, E. (2023) Is the region ready? Preparedness for CQC Assurance in the West Midlands, https://www.wm-adass.org.uk/media/bnqlpdm1/cqc-readiness-report-needham-burn-f1.pdf
Rubery, J., Hebson, G., Grimshaw, D., Carroll, M., Smith, L., Marchington, L. and Ugarte, S. (2011) The recruitment and retention of a care workforce for older people, London: Department of Health.
Skills for Care (2023) The State of the adult social care sector and workforce in England,
Stacey, C. L. (2011) The Caring Self: The work experiences of home care aides, Ithaca: Cornell University Press.
About the Centre for Care
This response is provided by members of the ESRC-funded Centre for Care. The Centre for Care is a research-focused collaboration between the Universities of Sheffield, Birmingham, Kent and Oxford, the London School of Hygiene & Tropical Medicine, the Office for National Statistics, Carers UK, the National Children's Bureau, and the Social Care Institute for Excellence. Funded by the Economic and Social Research Council, with contribution from the National Institute for Health Research (NIHR) and Department of Health and Social Care, as one of its flagship research centres, it works with care sector partners and leading international teams to provide accessible and up-to-date evidence on care – the support needed by people of all ages who need assistance to manage everyday life.
Led at the University of Sheffield by Centre Director Professor Sue Yeandle and Deputy Director Professor Nathan Hughes, our work aims to make a positive difference in how care is experienced and provided in the UK and internationally by producing new evidence and thinking for policymakers, care sector organisations and people who need or provide care. In studying care, we focus on ways of improving wellbeing outcomes and on the networks, communities and systems that support andaffect people’s daily lives, working closely with external partners.
January 2024
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