Written evidence submitted by the Alzheimer’s Society (RTR0050)

What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

Extra staff are desperately needed in social care. There are over 105,000 vacancies as reported by Skills for Care in October 2021, equating to a vacancy rate of 6.8%[1]. It is thought that the number of vacancies will have increased further since then, with the introduction of mandatory Covid vaccination as a condition of employment for working in care homes in November 2021. Urgent action is needed to address recruitment.

A key step that must be taken to support recruitment of staff in social care is improving pay. Pay for care home staff is low and surveys of care staff repeatedly show that pay is an issue. Care workers are paid a mean hourly rate of £9.29 in the independent sector and £10.77 in the local authority sector[2]. Median care worker pay (in the independent sector) was £9.01 per hour in 2020/21; compared to £9.07 for cleaners and £9.22 for retail assistants[3]. Other sectors, such as hospitality, are currently experiencing high numbers of vacancies too, and many are now increasing pay, as well as offering other benefits, to attract new staff to fill vacancies. Care pay is not competitive. Increasing pay would be a key step to make the sector more attractive to new staff and to help retain existing staff. Pay can also be a way of recognising and valuing staff for the skilled and important work that they do. While the issue of pay remains unaddressed it is likely to remain a key barrier.

There are other areas where change is needed to support workforce recruitment and retention. Priorities set out by adult social care leaders in their vision for a future workforce strategy, are staff recognition, value and reward (including pay, and support for wellbeing); investment in training, qualifications and support; career pathways and development opportunities; building and enhancing social justice and EDI in the workforce; effective workforce planning; and expansion of the workforce in roles which enable prevention and support the growth of innovative models of care[4]. Some of these areas are covered in more detail in later questions.

What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

Training that provides staff with skills and knowledge that are transferable across different roles and settings can support staff in moving between different roles and settings, which can be particularly useful as models of care evolve. The Dementia Training Standards Framework (DTSF)[5] applies across both health and social care, and has three tiers, for all staff (tier 1), staff directly supporting people with dementia (tier 2), and staff in leadership roles (tier 3). This framework can support consistency of skills and knowledge in dementia across different roles in both health and care. The Framework was commissioned by the Department of Health and developed in collaboration by Skills for Health and Health Education England in partnership with Skills for Care.

It is good to see the Government’s white paper on social care set out plans for working with the sector to co-develop a universal knowledge and skills framework (KSF) and career structure. The co-development of this will be key in ensuring it reflects the knowledge and skills that are needed by people who draw on care, and that staff working in care feel that they need.

Training also needs to be recorded in a consistent and accessible way so that different employers can easily see and understand the skills and knowledge that care workers have, so that staff can move between roles without needing to repeat training unnecessarily. It is good to see plans in the Government’s white paper on social care for a new care workforce hub to record data on training, and embed skills passports for staff so as they move between jobs they can evidence training they have had in previous roles.

Training is also important for developing the digital skills of the workforce. There is already great potential for digital and technology to support care, and the opportunities that arise from this are likely to increase further in future years.

Projections of care needs and workforce requirements for future years would support future proofing and planning for evolution of recruitment, training and retention as needs change. This should be done at both national and local levels. Evidence and data should be used to inform effective planning.

It is projected that the number of people with dementia in the UK will rise in future years, to nearly 1.6m by 2040, which is an increase of nearly 80% over ten years[6]. The number of people living with dementia categorised as ‘severe’ – and with high care needs - will reach over 1m by 2040, an increase of over 100%[7]. This will mean even more people working in care will be supporting people with dementia. It is important that everyone supporting people with dementia receives training in dementia that is appropriate to their role.

A long-term workforce strategy, underpinned by evidence and data, would help models adapt by planning for this in advance. There needs to be clear roles and responsibilities at both national and local level, for delivering on the strategy and for adapting plans where appropriate as population needs change. There should be a balance of national direction and local flexibility. Central to plans should be co-production with people who draw on care, and people who work in care.

Plans should be flexible, in being able to respond to changing need, and also to be able to incorporate findings from evaluation of action taken on recruitment, training and retention, building on success and changing plans where results haven’t been delivered as expected.

Long term funding for care will be vital to enable long term planning.

What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors?

Training needs to provide staff with the skills and knowledge they need to do their job properly from the start. Staff need to know, before starting a role in care, that they will be provided with the training that they need. When starting in the role, this is important so that they are able to do the job well and confidently. It also enables them to cope with the challenges of the work, so that they feel positive about the job and are more likely to remain in the sector. There should be a minimum level of training mandated for staff starting in care. This could be delivered through improvements in the Care Certificate so that it provides staff with the skills and knowledge they need when starting in this role, and that it is delivered consistently.

For dementia, all staff supporting people with dementia should be trained to tier 2 of the Dementia Training Standards Framework (DTSF). Tier 2 includes dementia identification, person-centred dementia care, communication, promoting independence, and families and carers as partners in care, and more. People with dementia have complex care needs as dementia affects everyone differently. The impact ofementia symptoms, which can include difficulties in communicating and expressing personal preferences, require care staff to have knowledge and understanding of the condition and how it can affect people to help them. This will help them develop the skills needed to provide quality care.

It is the right of staff supporting people with dementia to receive sufficient training to equip them with the knowledge and skills to do their job safely and with confidence when supporting people with complex care needs. The NICE dementia guideline[8] recommends that ‘care and support providers should provide all staff with training in person-centred and outcome-focused care for people living with dementia’, and ‘care providers should provide additional face-to-face training and mentoring to staff who deliver care and support to people living with dementia‘. It is estimated that 60% of people receiving homecare services have a form of dementia[9] and 70% of care home residents are living with dementia[10]; therefore many staff working in care will need training in dementia.

Personalised care is important for people with dementia, and for everyone drawing on care. Personalised care means a focus on supporting individuals to achieve goals that matter to them, supporting them to live a life with meaning, connection and purpose. It requires specific skills for staff to support people in this way and it is important both that the right staff are recruited, and that they receive the right training. It is good to see a vision for personalised care set out in the Government’s white paper on social care. It will be vital that care staff receive the training that enables them to deliver on this vision.

It is important that training is high quality and effective. Training should be evidence based, with evidence of the training delivering positive outcomes. However, researchers have found in a review of 170 training manuals for care home staff on person-centred care in dementia that only four had evidence that they worked when tested in a research setting. There are examples of evidence-based dementia training, for example the ‘WHELD’ programme for care home staff. Research has found this programme delivered benefits including significant improvements in quality of life, reduced agitation and overall neuropsychiatric symptoms, reduced use of anti-psychotics and fewer emergency or routine hospital admissions and fewer GP visits[11].

Ongoing training is important to support staff in further development of skills and to support career progression. There needs to be a career framework so that staff understand how they can progress and progression needs to be linked to training and increase in pay.

Training that supports staff in leadership roles is also vital. Staff need to be provided with the skills necessary to lead and support a team of staff to deliver care to the highest standards, and to support them in their own wellbeing. It is good to see some plans from the Government in its white paper on social care for improving training for those in leadership roles. The Dementia Training Standards Framework (DTSF) can support this, with tier 3 of this framework applying to staff in leadership roles.

For health care, GPs will be the primary clinician providing and coordinating care for the longest period of a person’s journey with dementia. It is therefore essential that GPs are trained sufficiently and have targeted time to undertake this training. However, previous research shows that GPs report insufficient basic and post-qualifying training in dementia, with overall GP knowledge of dementia low.[12] Potential seasonal covid vaccinations will impact capacity of GPs to undertake dementia care coordination and delivery if primary care is to lead vaccination delivery, as they have done for the past year. Future delivery of primary care must ensure that vaccinations do not hinder the ability of people to access primary care.

People with dementia often experience crisis which requires an acute admission. However, people affected by dementia have reported poor experiences of hospital care.[13] Previous research has found that not all hospital staff had the knowledge, attitudes and skills needed to deliver good care. It found supportive managers, organisational culture and a strong leadership were key factors in whether training was implemented.[14]

Dementia is a progressive and terminal condition; people will either die from dementia or it will be a contributory factor in their death. By 2040, annual deaths in England and Wales are projected to rise by 25.4%. If the trend of age and sex-specific proportions of people with palliative care needs remains the same as between 2006 and 2014, the number of people requiring palliative care will increase by 42.4%.[15] Disease-specific projections show that dementia is proportionally the biggest cause of increased need. If trends are sustained, by 2040, the annual numbers of people dying at home and in care homes will almost double. However, if there’s no expansion of capacity and end of life care training for staff in care homes and in home care services, the trend in declining hospital deaths will likely reverse by 2023.[16]

What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

Skills for Care have carried out an analysis of factors that affect staff turnover. It found these factors include pay, training, qualifications, and contracted hours. It reports: staff who were paid more were less likely to leave their roles; adopting valued-based recruitment can support employers to recruit staff that are more likely to stay long-term and to progress in the adult social care sector; retention was better when staff received training (the average turnover rate was 9.2 percentage points lower amongst care workers that had received some form of training compared to those that hadn’t); and staff with a relevant social care qualification were less likely to leave[17]. Addressing these issues has been covered in other questions.

It is also important to note the impact of the pandemic on the wellbeing of care staff, often working in very challenging roles and sometimes putting their own health at risk. There is an urgent need for improved wellbeing support for staff in recognition of this.

Measures to address these issues need to be backed by sufficient funding, to deliver transformational change for the 1.5m strong social care workforce.

Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

Workforce, or the lack thereof, has also been suggested as a potential barrier to diagnosis. In most local diagnostic services, consultant-level clinicians are required to confirm dementia diagnoses and consultants can come from a range of professions including psychology, gerontology, psychiatry and neurology, amongst others.

There has been significant difficulty in increasing the psychiatric workforce over the past five years. The Five Year Forward View for Mental Health and NHS Long Term Plan both included indicative workforce requirements to deliver service ambitions and improve mental healthcare, but the requirements have not been met nor are they on track to be met. In the plan to deliver the Five Year Forward View for Mental Health – Stepping forward to 2020/21: The mental health workforce plan for England – there was a target to employ 570 more consultant psychiatrists by March 2021. By this date, only 209 (37%) posts were filled compared with March 2017 (the Government’s baseline date).[18] Furthermore, the NHS Long Term Plan is meant to build on the planned workforce set out in the Five Year Forward View. Yet as of June 2021, the NHS was almost 400 consultant psychiatrists behind the target for 2020/21, and therefore on course to miss the Long Term Plan’s ask to achieve this target by 2023/24.[19]

When looking at old age psychiatry specifically, over the past year there has been a decrease in the number of consultant old age psychiatrists. For comparison, there were increases across three of the six specialties reported by NHS Digital: forensic, 3.7%; general, 3.1%; and child and adolescent, 0.7%. The other three specialties all had decreases in consultant numbers: learning disability, 1.8%; old age, 2.3%; and psychotherapy, 16.9%.[20] Similarly, The College for Radiology latest research also found there is a 1,313 WTE consultant radiologist shortfall.

What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

Social care needs a People Plan. This needs to set out immediate actions to address the urgent staffing shortage crisis facing the sector now, as well as setting out long term plans. As previously stated, there needs to be clear roles and responsibilities at both national and local level; and central to plans should be co-production with people who draw on care, and people who work in care. Long term planning can support sustainability of the sector and needs to be supported by long term funding. Any social care people plan must be developed in conjunction with the NHS people plan to ensure the two plans can integrate together and both are similarly ambitious. This will enable integrated care systems to develop integrated work forces across the two sectors when needed, and ensure a career in either sector offers competitive pay and similar workplace benefits such as in training and wellbeing support.

January 2022