Written evidence submitted by the Royal College of Nursing (ASC0097)

Royal College of Nursing response to Health and Social Care Committee inquiry into Adult Social Care reform: the cost of inaction

About the Royal College of Nursing

With a membership of over half a million registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

1. Background: Nursing in social care

1.1.   Registered nurses and nursing associates are key to the delivery of social care across England; however, the size of the nursing workforce has declined by more than 17,000 since 2012[i], putting vital care at risk.

1.2.   Nursing provision within social care is delivered by a range of providers, with significant capacity in the independent sector. There is no universal framework for pay, terms and conditions or banding of nursing roles. This leads to variation in nursing pay, terms and conditions between different individuals, and different services, even for equivalent roles.

1.3.   Registered nurses working in social care are sometimes the only nurse in that service, or they may work in a small team. This limits the opportunities to identify clear career progression steps. This contrasts with the NHS and other areas such as academia where clear roles and banding support individuals to identify the next steps in their career pathway.

1.4.   There are significant issues with nursing supply, recruitment and retention. This leads to vacant posts and staffing levels which do not deliver safe and effective care. In social care the continued decline of registered nurse numbers and turnover of nursing staff is of particular concern. There are also shortages amongst nursing support staff.

1.5.   We know that there are significant numbers of people from ethnic minority backgrounds working in social care. For example, people from ethnic minority backgrounds account for 20% of the social care workforce. Given that we also know that pay, terms and conditions are in many cases worse in the social care sector, it is important to ensure that equality, diversity and inclusion is a focus for all social care providers.

1.6.   There is evidence to demonstrate that the level of need for social care is higher than the current provision of care services. We also know that population needs are increasing as the population grows and the proportion of older people increases. We also know that there are increasing numbers of younger people and working age adults with complex health and care needs.

1.7.   Broadly, despite increasing needs within the population, the level of awareness and understanding about how social care works is low. This means that nursing staff often interact with patients, families and carers who need support to navigate the system, and who are often faced with difficult conversations about a lack of access to care, despite high needs. Any reforms must be accompanied by an honest, educational conversation about how social care works, how it is funded and how to access it.

2. A lack of long-term vision

2.1.   A long-term funding settlement is needed for all parts of the health and care system, including the NHS, that is based on the resources required to meet demand and deliver the transformation of services. Significant investment in preventive, community, primary care and social care is an urgent priority, so that they can be better equipped to reduce demands on hospitals and truly build an NHS fit for the future.

2.2.   The existing (2019) NHS Long Term Plan (LTP) and the (2023) NHS Long Term Workforce Plan (LTWP) were designed based on the assumption that there would be stability within the social care sector, so that additional, unexpected pressure was not placed upon the NHS through instability. In our view, it is impossible for the Government to deliver a new 10-year NHS plan, without a reciprocal plan and investment for social care and public health.

2.3.   Staff shortages across community and social care cause delays and blocks to patients being discharged into the community, leaving hospitals full and staff having to provide care in inappropriate settings. Shortages in specialist community roles, particularly health visiting and school nursing, also reduce opportunities for prevention.

2.4.   The NHS LTWP projected that by 2036/37 there will be a 37,000 FTE shortfall in community nurses.[1] This – alongside the crisis in social care which is also experiencing high numbers of nursing vacancies – is leaving thousands of people who are fit enough to go home delayed in hospital beds.

2.5.   Sustainable, long-term investment and reform in adult social care would alleviate pressure on the NHS, reduce spending on avoidable hospital admissions, and enhance care standards across the country, contributing to healthier communities and a more resilient healthcare system fit for future purpose. Pressures on social care inhibit the NHS from implementing crucial reforms, such as improved hospital discharge and community-based care enhancements. As a result, patients miss out on smoother transitions from hospital to home and on preventative services that reduce hospitalisations, which would improve public health and save costs.

3. Unequal distribution of investment

3.1.   Different funding mechanisms at local and national level provide the opportunity for parts of the systems to grow at different rates. As the gap in growth and investment rates increases, the system becomes more unstable. Demand naturally shifts towards areas with more capacity, regardless of whether that is the most suitable setting to meet their needs.

3.2.   An example of this can be observed in a lack of investment in the district nursing workforce often leaves social care services without the capacity and support they need. If a resident becomes unwell, they are more likely to take them directly to A&E, rather than being able to access community nursing provision. This is made worse by a lack of capacity within community and social care settings to care for patients safely once they are ready for discharge.

3.3.   In 2019 NHS England published the NHS Long Term Plan, designed to be an ambitious roadmap for the following decade of care. One of the key ambitions within this was to shift care from secondary health services (such as hospitals) into community settings. At the time, it was stated that “these reforms will be backed by a new guarantee that over the next five years, investment in primary medical and community services will grow faster than the overall NHS budget.[2]” Ultimately, this commitment has not played out in practice, and even before the COVID-19 pandemic there was a continued focus on and increased resources directed towards bringing down waiting times within secondary care services.

3.4.   The COVID-19 pandemic underlined the importance of robust public health services and further exposed the significant health inequalities that exist in England. Despite this, the public health grant which funds local authorities to commission essential public health services has been cut by 24% on a real-terms per capita basis since 2015/16, with cuts disproportionately affecting those living in the most deprived areas of England, who also tend to have poorer health. Underinvestment has impacted on the vital public health services provided by local authorities to promote wellbeing and prevent ill health, including smoking cessation, sexual and reproductive health, health visiting and school nursing.

3.5.   In recent years, additional investment has often tended to be short term and focussed on the NHS, particularly in terms of recovering from the pandemic and addressing the backlog. While this is welcome, there are many areas of the health and care system which have not received appropriate uplifts in funding. This has a knock-on effect; demand is higher than it naturally would be. This is a poor return on investment – public money is being spent on plugging gaps in other parts of the system.

3.6.   The most acute impact of this imbalance is that services cannot meet the level of demand they are faced with, and there is nowhere else in the system for that demand to be met. The demand spills out into ambulance bays, corridors, staff rooms and waiting areas. The cost of inaction is most evident in acute healthcare services, where delayed discharges and increased emergency visits due to inadequate social care contribute to overcrowded hospitals. Additionally, community healthcare bears significant pressure due to the higher demand for specialist complex care management outside hospitals.

4. A lack of investment in prevention

4.1.   There is a general acknowledgement in Government since winning the election that there is too much focus on acute services and ‘plugging gaps’, including in social care, at the cost of upstream interventions. It is our view that there has not been enough investment in prevention, which means that there is a larger cohort of people who are more unwell and needing a higher level of support from social care. In turn, this makes social care reform appear more costly, a key reason why multiple administrations have shied away from undertaking reform.

4.2.   There is significant evidence of the benefits of investment in prevention and public health.[ii] A focus on prevention can support reduced rates of illness and premature mortality and a healthier population, which in turn contributes to reducing pressure on overstretched health and care treatment services and increasing productivity and economic activity.[iii] In the context of acute pressures on health systems across the UK where care is too often being delivered in inappropriate settings because of overcrowding and overwhelming demand, it is clear that the case for a refocus on prevention and public health is critical. This is even more apparent when considering the future projections for the population, with an ageing population, the growing burden of disease and more people living with multiple complex conditions.[iv]

4.3.   Across the UK, governments and policymakers have recognised that ‘prevention is better than cure’ and made policy commitments to prevention and keeping people well and out of hospital for longer.[v] However, despite the rhetoric, there has been insufficient action to deliver on longstanding policy commitments to prioritise prevention and deliver more services outside of hospitals. Instead, there has continued to be a pattern of spending and focus on NHS treatment services and underinvesting in prevention.

4.4.   Funding cuts and underinvestment in public health and community services exacerbate the pressures on the wider health and care system as opportunities for prevention and early intervention are missed. Furthermore, rising rates of poverty in the UK[vi] and the impacts of the cost-of-living crisis increase ill health and inequalities and increase the demand for health and care services.[vii] For example, hospital admissions data shows a direct correlation between higher levels of deprivation and higher emergency admissions.[viii] 

4.5.   Despite successive governments in England committing to prevention and the need to strengthen community services, public health services and interventions have been subject to significant spending cuts, despite increased demand. The cuts have disproportionately affected those living in the most deprived areas of England, who also tend to have poorer health and higher rates of hospital admissions[ix] and attendances at Accident and Emergency.[x]

4.6.   The RCN has repeatedly raised concerns about the significant and widening gaps in the public health nursing workforce in England and the risks this poses for prevention and health equity. In relation to key areas of public health, notably health visiting and school nursing which are critical for prevention and early intervention in the early years, the RCN has highlighted concerns about funding cuts leading to services being decommissioned despite rising demand, and the resulting workload pressures affecting recruitment and retention, as well as concerning trends in skill substitution.[xi] Staffing gaps have also led to variation in service provision across different areas of England and a ‘postcode lottery of support’.[xii]

4.7.   Inaction on adult social care reform therefore creates a significant financial burden on the NHS and local authorities. Increased emergency admissions and extended hospital stays often occur because individuals cannot access timely social care, straining resources that could be better allocated. For patients, this results in delayed discharges and reduced quality of life, particularly for vulnerable groups, with the public ultimately funding these inefficiencies.

4.8.   For individuals, inaction leads to poorer health outcomes and delayed support, impacting both mental and physical well-being. Reform would enable timely, personalized care, helping people to live independently and with dignity, while reducing the strain on emergency services.

5. Poor practice within social care

5.1.   The cost of inaction to reform the social care sector is felt acutely by migrant care workers, specifically those on temporary and conditional visas.  Since 2022, skilled migration to the UK to occupy vacancies in the care sector has surged, with 80,000 migrants taking up direct roles in 2022/23, and 105,000 in 2023/24.  This has coincided with a rise in exploitation, modern slavery, and unethical labour practices.

5.2.   The Director for Labour Market Enforcement has assessed the care sector as high risk, given the prevalence of non-compliance with labour standards and cases of modern slavery. Most recently, in its 2024 report, it was found that non-compliance with the National Minimum Wage and non-payment was endemic in the care sector. The RCN has received increasing reports of repayment fees, which RCN members have reported to be as high as £16,000, charged to workers attempting to leave their employment before a specified time.

5.3.   The RCN is aware of cases where passports have been taken and wages withheld to enforce payment of these fees. Internationally educated members also report being offered fraudulent job offers. In some cases, nursing staff have been scammed into paying up to £20,000 in illegal work finding fees.  The Gangmasters Labour Abuse Authority (GLAA) has also found evidence of labour abuse in the sector, including overcrowded accommodation, payment below minimum wage, and debt bondage.

5.4.   In 2023, the GLAA received 123 reports of modern slavery and human trafficking within the care sector, with the sector representing between 26% and 48% of all referrals made in each quarter.  The RCN hears that members are reluctant to report instances of exploitation, as the health and care visa is conditional on their employment – if they lose their job, they lose their sponsorship. This condition is often used as a threat, both directly and indirectly, to RCN members from employers to keep them in exploitative positions, working unreasonable ours for un-substantive pay. Inaction on exploitation has permitted unscrupulous employers carry out unethical labour practices, at great cost to vulnerable workers, and may affect the future workforce.

5.5.   Skills for Care have predicted that 540,000 new social care workers will be needed by 2040 to meet demand in the sector. Failure to stamp out exploitation may encourage workers to leave the sector. Effective reform of the sector would serve to protect and empower migrant workers to report wrongdoing where they see it. This should take the form of a fully realised, funded, and Government single enforcement body, effective regulation of the care sector, and the adult social care negotiating body. This is proposed as part of the Employment Rights Bill. 

6. RCN recommendations

6.1.   A lack of investment in social care leads to corridor care in other parts of the system. To tackle corridor care, we are calling on the Government to:

6.2.   Address the registered nurse workforce crisis

6.3.   While it is vital that service provision and overall investment is increased, it is essential that the registered nurse workforce crisis is also resolved to ensure that services can deliver their full potential. Safe and effective levels of nurse staffing are critical to patient safety, outcomes and experience. Appropriate levels of nursing staff can reduce patient complications and overall length of stay, which contributes to seamless patient flow through health and care services.

6.4.   Understand the ‘true’ demand and how this correlates with the provision of beds and services.

6.5.   Corridor care is a clear indicator that the health and care system is not coping with the level of demand it is faced with. We do not have assurance that governments have a clear understanding of what the true demand for health and care support is within the population. Often ‘demand’ indicators (such as attendances at A&E or waiting lists for treatment) are artificially low due to restrictions of access to support.

6.6.   Uplift investment in all parts of the system

6.7.   We call on governments to ensure that when investing in one part of the system, they must also increase the level of investment in services that are likely to receive a higher level of demand in response. For example, if a government were to invest in increasing the provision of mental health awareness and community support services, they should also invest in secondary mental health services, knowing that there will be an increase in demand. There is a need for long term sustainable investment as part of a coherent approach which considers the needs across all parts of the system.

6.8.   Introduce new Parliamentary reporting requirements.

6.9.   We call for parliamentary-level reporting on the instances of corridor care every quarter alongside an overview of the actions Governments are taking to reduce occurrences, with the opportunity for politicians to debate the issue. This will become an additional duty for the relevant minister, to ensure that their briefing includes specific responsibility for reporting on corridor care.

7. Wider social care recommendations:

7.1.   Ensure accountability for social care decision making

7.2.   There must be specific accountability for ensuring the provision of social care meets population needs. We know that there are situations where instability in the provider market leads to needs being left unmet, or care being left undone often at short notice to the individuals and staff involved. Local decision makers should respond to escalation to mitigate and prevent situations where gaps are formed within local care provision.

7.3.   In some areas there is instability within the social care provider market. This can lead to poor pay, terms and conditions, service changes and a lack of secure employment. It is important to ensure that staff members from under-represented groups are not disproportionately affected by changes. Equality impact assessments can be a useful tool for identifying the impact of proposed changes. Clear accountability frameworks delivered through regulation, inspection or other points of transparency.

7.4.   Long term investment

7.5.   There is a need for additional, sustainable and long-term investment in the sector, a recognition within service planning for people of all ages, and an opportunity to keep couples and families together. Specific attention should be given to learning disability services, mental health services and the needs of both old people and children and young people within social care. We are calling for a long-term funding settlement for social care settings in all parts of the UK, based on a robust assessment of population needs.

7.6.   Tackle racism and discrimination

7.7.   The UK Government must invest in a cross-governmental strategy to tackle both race inequality as it is woven into the operation of institutions as well as health inequalities which sets out clear objectives, measurable recommendations and timeframes with the funding required to achieve them.

7.8.   We expect that employers carry out comprehensive equality impact assessments and risk assessments on staffing issues, including reviewing the allocation of shifts. This is most important for redeployment of high-risk staff to the frontline and must be done with their consent and to ensure that the overall impact of change delivers equity, support and protection for staff.

7.9.   Fair pay, terms and conditions

7.10.                      Overall funding for social care must be sufficient to provide fair pay, terms and conditions for all nursing staff. Investment levels must also fund staffing for safe and effective care in all social care settings. Funding should consider wider health promotion and prevention, which nursing staff are key to, and which can allow earlier identification and intervention for individuals.

7.11.                      Commissioners must take account of sufficient workforce requirements, and fair pay, terms and conditions that reflect the knowledge, skills and responsibilities equivalent to Agenda for Change grades, when planning and funding services.

7.12.                      Promote the role of nursing in social care

7.13.                      National bodies should investigate ways to introduce clearer career pathways to promote all nursing roles in the sector and/or promote movement between social care and the NHS (on a secondment / training arrangement). 

7.14.                      National bodies (including Government where appropriate) should undertake campaigning to promote the role and profile of nursing within social care to recruit newly qualified and existing nursing staff into social care settings.

December 2024