Written evidence submitted by the Association of Directors of Adult Social Services (ADASS) (RTR0047)

1)                   ADASS welcomes the opportunity to respond to the Health and Social Care Committee inquiry. The recruitment, training and retention of the social care workforce remains a key challenge for social care. The Covid pandemic has highlighted how outstanding the adult social care workforce is and how crucial it is to the lives of many people who draw on care and support.

2)                   Covid 19 has brought adult social care to the public’s attention more than at any time before whist also exposing the fault lines which were in existence and worsening pre Covid. Low pay, poor terms and conditions, lack of career development, EU Exit, staff burnout, vaccination as a condition of employment and competition from other sectors are all critical factors on their own but combined, they have created a perfect storm. Many ADASS members believe recruitment and retention in the sector is now at crisis point and the worst they have experienced. In September 2021 we completed a rapid snap survey of our Membership who are all serving Directors of adult social care. [1] This survey was followed by a second survey in November 2021[2] which showed a worrying worsening trend:

• Almost 400,000 people were waiting for an assessment of their needs or service; (up from 300,000 in Sept)
• More than 1.5 million hours of commissioned home care could not be provided between August and October because of a lack of staff, despite record growth in provision;
• One in two councils has had to respond to a care home closure or bankruptcy over the past six months.

3)                   It has become ever more apparent that the sector cannot continue to limp along, from crisis to crisis, relying upon a social care workforce largely paid the minimum wage whilst performing a crucial and highly skilled role.

Why this Review is Needed

4)                   The Adult Social Care workforce consists of over 1.5 million people working in over 1.65million jobs in a wide variety of settings. There are many more not considered social care workers but none the less doing social care and support work, including those in hostels, refuges, and night shelters, in community and contracted voluntary sector schemes. Coronavirus has only highlighted the professionalism and dedication of social care and social work staff and the lengths they have been willing to go to in maintaining the highest possible levels of care in the most difficult and challenging of circumstances.

5)                   Social care is an essential part of the fabric of our society: it transforms lives. It enables millions of us to live the lives we want to lead, where we want to live them. It supports people at the most critical times, in all stages of their lives, but with the same core objective of providing the care and support which people need to live good lives and die good deaths.

6)                   It is impossible to consider the paid care workforce without considering the interplay with unpaid carers supporting, sometimes 24 hours a day, family, and friends. When there are shortages of formal care there are few options other than the person concerned going without or family and friends stepping in, both at significant cost to people’s health and economic, social, and psychological wellbeing and to the economy.

7)                   As well as supporting the well-being of millions of us and our families, social care contributes to the economic wellbeing of our communities. The adult social care sector in the UK contributes £46.2 billion to the economy representing 6% of total employment.[3] It is a major local employer, and any expansion of social care means new businesses, new job opportunities, increased tax contributions and a significant net contribution to the local and national economies. It is not the drain on the economy which is so often portrayed. Adult social care is a positive force in our lives and within our society. It is critical that the sector is viewed in this light and workforce planning for adult social care is given the priority which a sector employing so many people deserve.

8)                   For too long the skilled and compassionate adult social care workforce has been undervalued. Colleagues working in adult social care have been paid less than their NHS colleagues, too many have been paid at or just above the minimum wage, there has been insufficient training and development support, and vacancy and turnover have been much too high. This is the unfortunate background to a sector struggling to recruit and retain staff. There were over 100,000 social care vacancies going into the pandemic and this has been exacerbated by EU exit and vaccination as a condition of employment.

9)                   Unlike the NHS, adult social care has not had a national workforce strategy. This is a huge gap that must be addressed. As part of the long term reset and rebuild of adult social care, we must prioritise social care work. The recent publication of ‘People at the Heart of Care: adult social care reform white paper’ contains a sector entitled ‘Our strategy for the social care workforce’. Whilst we recognise and welcome the intentions in the white paper to develop and support the workforce it does not go nearly far enough to solve the long-term systemic issues which blight the sector.

10)               There is nothing in the white paper which sets out a strategic plan about what is needed from the workforce in a reformed social care system, what roles are required and in what number and what the skill mix should be. Critically, there are no commitments around raising the salaries of social care workers other than reference to an increase in the national minimum wage. With respect, training and development are important but without forecasting, planning and the resources to pay staff decent wages and a pay structure that retains them this workforce section of the paper is not a strategy. And without such a strategy, the year on year short term crisis funding will continue and the government’s reform initiatives will flounder.

11)                    In the ADASS Budget and Comprehensive Spending Review submission (September 2021) we called for Government to implement a new employment deal for care staff, including a workforce strategy, adult social care minimum wage, enhanced training, development and career progression, recognition and regulation. In this we recommended the introduction of a specific Adult Social Care Living Wage that is level with Band 3 NHS of approximately £11.50.

12)                    If we truly respect our social care workforce and value the life enhancing and life saving role they play, then we need to move away from referring to care as a minimum wage occupation. One thing has become abundantly clear during the pandemic, if we continue to rely upon a minimum wage offer then our competitors for staff (retail, hospitality) will always be able to pay more and offer better conditions.

13)                    ADASS has welcomed the recent workforce grants which Government provided to the sector to help address current staffing shortages. The grants followed a call from ADASS for Government to provide funding to award social care staff a £1000 bonus to help retain staff in the sector over the Winter period in order to reduce the leak of staff to other better paid but often lesser skilled work. The quantum of the funding provided has not been sufficient to facilitate this, however local authorities have been working creatively with Providers and with ICS systems to offer incentives to staff including NMW rises being brought forward or smaller bonus payments introduced.

Current Workforce Data

14)               In 2020 ADASS set out the steppingstones for change in adult social care by publishing ‘Adult Social Care – Shaping a Better Future.  adult-social-care-shaping-a-better-future-nine-statements-220720.pdf (adass.org.uk) . This publication included nine statements setting a vision and framework for a reformed social care sector. It is critical to reflect upon this when thinking about long term care, support and safeguards and the workforce which will be needed to deliver this as we know that care and support cannot be delivered in the same way going forward. These considerations should form part of a national workforce strategy.

15)               Long term social care reform is the primary and overriding factor which should shape what the care workforce will look like in 15 years. There are a multitude of factors which have blighted the sector with workforce shortages for many years and at the time of writing this there is a workforce crisis. The following captures workforce data pre Covid 19.

• The estimated turnover rate of directly employed staff working in the adult social care sector was 30.4%, equivalent to approximately 430,000 leavers over the year. Around 66% of jobs were recruited from other roles within the sector
• It is estimated that 7.3% of the roles in adult social care were vacant in 2019/20, equal to approximately 112,000 vacancies at any one time.
• Around a quarter of the workforce (24%) were on a zero-hours contract (375,000 jobs). Almost half (42%) of the domiciliary care workforce were on zero-hours contracts.
• 82% of the adult social care workforce are female, the average age of the workforce is 44 years and 27% of workers are aged 55 and above.
• 7% (113,000 jobs) of the workforce had an EU nationality[4]

16)               These figures have shifted significantly over the course of the pandemic and there is currently a crisis of service continuity due to workforce shortfalls and isolation which have increased rapidly over the past 12 - 18 months. Few of these issues can be solved in the short term, although short term action is vitally needed, and so a longer-term plan based upon predicted needs is required.

Reform and Transformation

17)               Within the context of a social care reset, our shared goal must be to join up and coordinate care around the individual. For too long care has been built around organisations and buildings such as hospitals, day care centres and care homes. The future must be about what works for us as individuals and our families, with a whole series of local organisations working together to organise care and support that enables us to work, stay independent at home, and be as engaged in our communities as we want. Wellbeing is central consideration to all that we should do. The future workforce therefore needs to reflect these shared goals and ambitions.

18)               This is a vision which overlaps with  the NHS 10-year plan which emphasises a change in direction for healthcare in England. That it should be person centred, compassionate and based around the wishes and aspirations of the person rather than the needs of the system. Fundamentally, this is a human rights-based approach that values everyone’s autonomy and rights to self-determination. The changes expected by the 10year plan will therefore necessitate a fundamental shift in attitudes and behaviour from all those working in the health and care sector. A reformed health and social care system based around the individual will see an ongoing shift from NHS care to social care and support increasingly delivered in the community requiring new roles with transitional skills with education, training, and workforce development essential to this. This requires significant financial investment to make this work.  Again this isn’t address in the recent white paper publication.

19)               A reformed social care system will need to match the changing expectations from those directing their own care and support to live the lives they want. This will see changes in models and levels of care as we see a further progress made in planning alongside people for more housing based, personalised forms of care and support. This will mean a return to the true values base of preventative community based social work and social care rather than solely an intervention at a time of crisis response. This will be supported by improving digital solutions to supporting people to remain independent.  There needs to be recognition that social care is far more diverse than supporting older people in residential care or facilitating hospital discharges which is often the political and public perception of care. The workforce of the future needs to reflect this.

20)                

21)               Social work and social care mean prevention in relation to mental health, diversion from custody, release from the criminal justice system, substance misuse and addiction, domestic abuse, mental ill health and parenting, more focus on transitions and supporting people in setting up home, involvement in employment, relationships, and transitional safeguarding. It is about social and community support rather than an over medicalised model of care and treatment.

Impact of Changes Due to Covid

22)               Covid 19 has brought adult social care to the public’s attention more than at any time before whist also exposing the fault lines which were known pre Covid. Low pay, poor terms and conditions, lack of career development, EU Exit, staff burnout, vaccination as a condition of employment and competition from other sectors are all critical factors on their own but combined, they have created a perfect storm. Many ADASS members believe recruitment and retention in the sector is now at crisis point and the worst they have experienced.

23)               We must take the learning from Covid as we plan for the long-term future of social care and its workforce. It must be viewed as importantly as doctors and nurses are in acute hospitals. Covid will leave a societal legacy of increasing health and social care demand for some time to come. Covid has hit sections of society harder than others, and this has yet again brought into focus widening health inequalities and increases in poor wellbeing, poor mental health, substance misuse and other addictions, increasing need for care and support and safeguarding.

24)               We are yet to fully understand the long term physical and mental health repercussions of Covid, but we can see the extensive waiting lists for overdue assessments, reviews and treatment and the growing pressure on an already over stretched social care system as well as waits for acute care. Indeed, waits for acute care are impacting on the need for social care Covid could be a factor of life for many years to come impacting upon those already vulnerable to illness, isolation, abuse and mental unwellness as well as the wider population with the long-term impact of infection still to be understood.

25)               We need to rethink how we train, develop, and support the whole social care workforce. During the pandemic we could see the hugely significant role Registered Managers played yet we know they are in short supply and the experience of Covid may see a number leave the roles. Excellent leadership is a key factor in the delivery of high-quality care and the sector can simple not afford to lose Registered Managers now or in the future. We need to encourage staff working in care to want to become Registered Managers offering a clear career pathway for them whilst also recognising the contribution of those currently in the role and offering incentives to stay. For these reasons we support the specific focus on Registered Managers in the white paper. 

26)               The sector has struggled to recruit and retain adult Social Care Nurses who can work in the NHS for better pay, terms, and conditions. Social Care Nurses feel unrecognised and undervalued compared to the public support offered to NHS nursing staff.  We need equity for Nurses to work in social care who will become ever more important as we see a greater shift to care and support in the community with increasing acuity of those people living in social care settings requiring greater nursing input and care in the future. The recent announcement of a 3% pay increase for NHS nurses but not for ASC nurses is another example of the lack of parity and equity between the NHS and social care staff which creates divisions.

27)               Social Workers have worked tirelessly throughout Covid, but their efforts have been largely unrecognised outside of the sector. They have continued to support people in the most difficult circumstances – when they are experiencing abuse or neglect, at risk of deprivation of their liberty or human rights, when doctors are considering compulsory admission or treatment. Social Workers are key in supporting strength-based conversations to assist people to remain an integrated member of their local community. They also provide the link for individuals and families as they broker conversations across communities, and this again will be ever more important in a reformed social care system. Within the Social Work profession there are national shortages in certain roles such as Approved Mental Health Professionals (AMHPs). We have already seen a huge surge in demand for Mental Health services because of Covid so we would like to see a revision in post qualifying training for mental health professionals, enhancing what is already available to prepare people to train as AMHPs.

Demographics

28)               The following sets out several factors which we believe are critical to the future social care workforce. We do not have the skills to forecast and model what is needed over the years but are areas where we believe SfC and HEE should focus.

29)               One of the key drivers behind the need for social care workforce reform is demographic change. Demographic change along with changing models and expectations of care and supporting more people in the community with increasing acuity means that we will need more people working in social care than ever before. In the context of the whole labour market, employers also need workers who are able to work with them because their family members have good care. When considering the impact of demographic change this must also include the demographics of the workforce itself. 

• A growing and ageing population

The population aged 65 and above is projected to grow from 10.5 million to 14.1 million between 2020 and 2035. One adult social care job is required for every seven people aged 65 and over. Based on growth of the population aged 65 and above, by 2035 the sector may need 520,000 new jobs (32% growth).[5] This of course is set against a backdrop of a sector which pre-pandemic averaged a vacancy rate of around 7% or 120,000+ vacancies at any point.

• Increasing care and support needs

The number of people aged 18-64 with a learning disability, mental health need, or a physical disability is also projected to increase over the period, together with the impact of Long Covid. In addition to this we know that the acuity of care needs of people in receipt of social care is increasing with many people managing multiple long-term conditions at home. For several years social care has increasingly provided support to people with more complex care and support requirements who would have previously been supported by the NHS.  The numbers of people surviving a stroke is an example of this. In the UK there are over 1.2 million stroke survivors with two thirds of survivors leaving hospital with a disability with the average age for someone having a stroke decreasing, with over a third of strokes in adults between 40 and 69. This means that there is a requirement for increased rehabilitation or reablement support.[6]

• The shift of care from the NHS to social care over the decades is continuing.

In the 70s older people had support from district nurses and home helps, care homes were rare, and the last resort was the geriatric hospital. There is now a changing expectation of the NHS on ASC. ASC is not a ‘blue light’ service and therefore does not have the resources and infrastructure to provide full weekend and holiday cover.  Care staff undertake many of the supports that would previously have been given in community hospitals but with dreadful pay and minimal, sometimes cursory supervision and support. The nature of ASC being very much ‘outside; a clinical governance structure also means the workforce take more responsibility and significant decisions on risk which is not reflected in the T & C’s, learning and development and supervision and support of ASC staff.

Consequently, as well as additional staff numbers the sector also requires staff who are trained (e.g., Occupational Therapists) to work with people in a personalised way to address better Quality of life for people with disabilities in social care.

• Growing older without children or support from families

Britain is an ageing society and there are now over 1 million people aged over 65 who have never been parents. This is predicted to double to 2 million by 2030. People who are ageing without children are a third more likely to be carers for their own parents with all the difficulties this brings in terms of employment, stress, and isolation. In the longer term it raises questions about care and support for people without children and who will provide this.[7] Demographic changes have also seen more families living a greater distance from one another and people facing multiple caring responsibilities where they are caring for parents, children and grandchildren preventing them from providing the level of informal family care which they once did.

• A workforce which represents the community

The adult social care workforce in 2019/20 comprised 82% female, and only 18% male workers. The average age of a worker was 44 years old, and over a quarter of workers (410,000 jobs) were over 55 years old. Black, Asian, and Minority Ethnic (BAME) workers made up 21% of the adult social care workforce. This was more diverse than the overall population of England (14% BAME) however people from a BAME background are not equally represented in leadership roles.[8]

• More people are living alone

By 2032 11.3 million people are expected to be living on their own, more than 40 per cent of all households. The number of people over 85 living on their own is expected to grow from 573, 000 to 1.4 million. As more people live alone into older age there will be a greater requirement for formal care and support as informal or family support will be less available.

• I Levelling up, prevention and inclusion

Covid has exacerbated existing inequalities relating to several people in relation to their needs for social care, support, and safeguards:

• older people at the end of their lives and the level and types of support available to them (would there be any suggestion that a younger person might move into a 100+ place nursing home, for example?)
• people with a learning disability who had a 7 times higher rate of mortality from Covid than others,
• rough sleepers and substance misusers
• people with existing mental ill health and the increasing numbers of people becoming unwell
• older and disabled people whose domestic circumstances became abusive and invisible during lockdowns
• BAME communities and individuals
• People discharged from hospitals quickly, especially to care homes, without social work support to consider their options and the implications
• Poorer communities:  Men and women in the highest socio-economic class can, on average, expect to live just over seven years longer than those in the lowest socio-economic class, and more of those years will be disability free. This demonstrates that the need for care and support will continue to be highest in areas of deprivation and poverty.
• The largely female workforce, amongst whom the mortality rates have been the highest of any sector, and higher than those working in health.
• The future offers an opportunity to address these inequalities and to invest in preventative and inclusive forms of support that reduce patterns of crisis response where people end up in acute hospitals, residential care or prisons. New models of care such as those outlined in the White Paper and many more will need to be developed on a more extensive basis and more quickly, but all have staffing implications.

January 2022