Written evidence from Age UK

Introduction

The National Audit Office report into the adult social care workforce provides a detailed and comprehensive critique of both the nature and causes of the current workforce challenges, and one that Age UK absolutely recognises in our work.

It is our view that the social care workforce is in crisis. On any given day the care system is running about 82,000 short on staff, including 1600 social workers, over 60,000 care workers and 3400 registered nurses. High vacancy and turnover rates are already impacting on the care that people receive and, given that demand for care is rising rapidly, the problems will only become more acute.

It is vital that the forthcoming Green Paper takes steps to improve working conditions for those employed in care, and address those issues that prevent the system from taking a long term approach to staff development and workforce strategy. Ultimately this will mean addressing the underlying systemic crisis in adult social care. 

Consequences of high vacancy and turnover rates

Undermining the quality and effectiveness of care for service users

High turnover rates in the care sector have a profoundly negative impact on the experiences of service users and their families in a range of ways.

The most obvious and distressing consequence is the lack of continuity of care – particularly for individuals receiving care at home. Age UK regularly hears from older people and families who are sent new care workers on such a regular basis that it is fair to say that, in the most extreme cases, they never really know who is going to show up on any given day. Recent participants in our social care focus groups have described their experience as a ‘revolving door’ with nearly 50 different care workers in one year alone.

Receiving care is a deeply personal experience. Not only are care workers helping people with intimate acts, such as bathing and using the toilet, but providing any form of care to a high standard requires a positive and trusting relationship between those providing and receiving support. Developing a rapport, getting to know an individual and how best to meet their needs all takes time. Lack of continuity clearly undermines any aspiration to provide truly person-centred care. It can also have serious repercussions for someone’s wellbeing if, as is too often the case, it results in less effective oversight and monitoring of their health conditions, mood or changes in cognition. Essentially knowing someone well enough to know when they are ‘not right’ and notice changes over time is vital.

In a recent Richmond Group and King’s Fund report, Real Lives, one of the case study participants, Robert, described his experiences saying:

“It was difficult trying to get to know a lot of people as well in a very short space of time. I’m still active up here [points at head], but I’m at their mercy. I have to use a special fork and I drink with a straw and it’s got a lid lip on so I can open it, but I, yeah, I felt very badly handicapped by having different care workers nearly every day.”[1]

Furthermore problems of turnover and high vacancy rates affect staff at every level, including management. As a result, service users and their families can find it difficult to resolve problems and complaints or find someone accountable for the quality care. Again Robert describes struggling to deal with care agencies at every level:

“They changed their names four times while I was with them. The management changed every six months and that made it difficult for you to communicate with the managers if things went wrong. The field care supervisors were, well, they just couldn’t care less, that was their attitude, because their jobs, I think, were on the line anyway and then all of a sudden, without any warning, they decided they wouldn’t deal with disabled people. So they sent us back to the council.”[2]

Lack of continuity also limits what care can achieve. High quality social care should not be ‘task-focused’, it should support older people to set and achieve the goals and outcomes they want from their care. Yet it is clear that care staff and service users are not able to properly engage in working towards goals when there are unsure of who will be delivering care week-to-week. In particular it can undermine the effectiveness of short courses of reablement and intermediate care where this lack of continuity disrupts shared commitment to goals and objectives.

Robert describes being made to feel ‘small’ when he felt that care staff tried to insist that he could do more for himself. He describes an experience in which it is clear he had no sense of working towards shared goals within a trusting relationship that provided the right support and encouragement.

“I find them [council staff] extremely difficult, they won’t accept that I can’t do certain things. Now, I’d love to be able to make you a cup of coffee, but if you want one, I’m afraid I’ll have to ask you.”[3]

Creating a vicious cycle

High turnover and vacancy rates can become something of a vicious cycle. Higher rates increases pressure on existing staff, leading to a poorer working environment, which in turn leads to greater workforce churn and worse outcomes for older people.

In particular it is concerning that some of the highest turnover and vacancy rates are for registered managers (11.3 per cent) and registered nurses (9 per cent)[4] – or for those roles with high levels of responsibility for managing services and the quality of care provided.

As the Care Quality Commission notes, ‘strong leadership has a pivotal role in both high performing services and bringing about improvement in adult social care’. Yet of the five areas the CQC review ‘safe’ and ‘well-led’ have the poorest ratings with 22 per cent of services requiring improvement, as opposed to19 per cent overall.[5]

Limiting access and reducing choice

Care is a hyper-local market. People are obliged to ‘shop local’ and have very few options if their local care market cannot meet their needs or preferences. Likewise care providers are largely dependent on recruiting locally and, as a result, are particularly sensitive to local economic conditions.

In areas with high vacancy rates, older people and families can find that they have very limited choices or, in some cases, may find it difficult to access care altogether. This is particularly a problem for more rural communities. Providers, and usually the care workers themselves, are only paid for ‘contact time’ with their clients. Longer journey times between clients and/or without a critical mass of clients in a particular location can mean that providing services to those individuals just does not make sense financially. Rural England recently highlighted problems in recruitment and retention as one of the real challenges for home care business in their recent report Issues Facing Providers of Care at Home to Older Rural Residents[6].

Even when overall vacancy rates are not a significant problem in an area, there may still be specific recruitment and retention challenges for key skills or specialist services – particularly nurses. There is already a post code lottery and declining access to key and specialist services in many parts of the country leaving people struggling to access suitable care. Unfortunately this tends to impact the most on people with the highest levels or most complex needs, including those living with dementia.

Improving recruitment and retention

Stabilising the care market

The challenges facing adult social care in recruitment and retention go hand in glove with the wider systemic crisis in care and the impact this has on the care market.

It is widely acknowledged that the care market is in a precarious state and under significant financial strain. The Care Quality Commission’s most recent State of Care report paints a concerning picture. It reports that between 2015 and 2017 almost 4,000 nursing homes beds were lost – a 2 per cent total reduction. It also highlights significant churn in the home care sector with around 500 agency registrations and 400 de-registrations each quarter.[7]

Likewise the Association of Adult Directors of Social Services latest Annual Budget Survey report found 39 per cent of councils had had at least one home care provider cease trading in their area and 44 per cent at least one residential care home. Over the same period 37 per cent of councils had at least one home care contract ‘handed back’ as providers withdrew from the local authority funded market.[8]

Financial instability, high levels of ‘churn’ amongst owners and operators and a prevalent view that the market is unsustainable creates an environment where workers, probably rightly, feel they do not have much job security and few long term prospects. 

At the same time this uncertain climate also prevents providers and local authorities investing in long-term workforce planning.

As the National Audit Office report notes, between 2010/11 and 2016/17 local authority spending on care reduced by 5.3 per cent in real terms. The report further concludes that there is little sign of relief with spending power for local authorities forecast to fall by a further 0.2 per cent in real terms between 2017/18 and 2019/20, and certainly no promises beyond this point that what additional funding has been made available for care will continue.[9] In this context it is hard to see what would enable providers to commit to long term investment in their workforce, or indeed how local authorities could find the resources to support that goal.

Ultimately solving the workforce crisis in care will only be resolved by taking the action required to put the system as a whole on a secure and sustainable footing.

Improving pay and conditions

Ultimately the question of recruitment and retention comes down to how attractive a prospect care work is compared with other options available to the workforce. As set out above, care is a hyper-local market and care providers are largely seeking to recruit locally as well. Therefore to some degree providers are facing different challenges in different areas. For some the greater problem may be local skills shortage that makes recruitment into particular roles difficult. For others, local labour market conditions may mean providers struggle to compete with terms and conditions offered elsewhere.

However low pay, poor conditions and low status are common themes:

• Unsurprisingly tackling low pay and poor conditions has an important role to play in improving recruitment and retention. Skills for Care has found that staff on the lowest wages and those on zero hours contracts were among the most likely to leave their role. Turnover rates for people earning £7.20 to £7.49 per hour were much higher (29.8 per cent) than for those earning £8.70 or more (17.9 per cent).[10]

This is perhaps particularly pertinent given that care work is particularly low paid for the amount of responsibility and skill required. Care workers are responsible for the safety and wellbeing of very vulnerable people where the consequences of something going wrong can be significant for both the service user and the care worker. The mental and physical demands of care are also substantial. Although Skills for Care note information on reasons for leaving and destinations should be used with caution (as data often is not collected by providers), it is nonetheless telling that (where known) more than a third of workers leave the care sector altogether.[11]

• Rates of pay, opportunities for training and progression are largely better in the NHS for similar roles – a focus on improving parity between care sector and NHS roles would be greatly beneficial. This presents a particular challenge for recruiting and retaining nursing staff as there is already a perception that their work is not as valued as much as colleagues in the health service. Skills for Care shows that around 14 per cent of leavers move on to the health sector (again where their next employer is known).[12] 
• Investing in staff wellbeing and improving their access to professional support and networks is also key. NHS staff, for example, have much greater access to professional, organisational and local networks for peer support, training and quality improvement. Conversely the care sector is much more fragmented with many small providers. Staff are often quite isolated – they may be working alone in the community, or be the only member of staff with particular skills or responsibilities on duty at any given time. This can be both stressful and lead to unsafe or lower quality care. 

Staff need have adequate time for breaks and handovers, and be supported to feel mentally and physically able to cope with the demands of caring for people with high and complex needs, particularly those with dementia. Staff also need to be able to access support from other professionals. Staff in the NHS have support from consultants and the wider multi-disciplinary team, whereas therapeutic staff in social care settings are often particularly stretched and more professionally isolated.

Addressing terms and conditions for care sector workers needs to be seen in the round. While improving rates of pay and investing in support and training does have funding implications, as things stand providers are routinely incurring costs involved in recruiting and inducting new staff and in employing agency workers to fill vacancies. These in turn are passed on to care recipients, local authorities and the NHS.

Improving access to training and continued professional development

Access to training and continued professional development is often very limited within the care sector. The majority of the care workforce are not registered professionals with few formal requirements for qualifications or training, therefore there is little ‘top down’ obligation to invest in training. Nonetheless in our experience local authorities and providers are very keen to upskill their staff, however, as set out above, uncertainty and instability in the market means there is insufficient money or opportunity to engage in meaningful workforce planning or skills development.

Day to day pressures on staff and tight budgets mean it can be very difficult for providers to release staff during their shifts to attend training. As a result, staff often have no option but to invest their own time and money in improving their skills. Age UK has frequently run free to attend events aimed at improving dignity and nutritional care, we largely find people from the care sector attending in their own time and at their own expense.

Equally, it is important to recognise that facilities for training and development are often very limited. Many care workers spend their day working alone or in small teams in people’s homes without access to computers or opportunities to meet collectively. Likewise many care homes have limited IT access. As a result it is often hard for care workers even to access online training materials. 

There is no shortage of high quality materials and training available, what the sector lacks is the practical means to implement and access it at local level. Any new workforce strategy will need to address these challenges.

Financial support for apprenticeships, training bursaries and offers of the same benefits and rewards that colleagues in the health service would be a good place to start. Staff should be supported throughout training and be paid when attending courses.

Improving the image of working in care

The public perception of a career in caring urgently needs to be improved. Social care providers are often competing with employers in hospitality or retail where terms and conditions may be better, for work that is seen as less mentally and physically demanding with less jeopardy.

Caring is and should be regarded as a vocation, more than a job but a commitment to supporting the recovery of those in need. We need to value a career in caring in the same way as a career in nursing with a focus on outcomes, recovery and quality improvement.

This must start, however, with valuing the contribution of the care sector as a whole. The perception of care work as low status and with few opportunities for progression reflects, at least in part, the low priority and visibility of the care system, particularly in comparison to the NHS.

Developing the role of the care system to meet the needs of a growing older population, including a much greater focus on supporting wellbeing, recovery and enhancing people’s quality of life would help improve the image of caring. Investing in ‘enriched’ care environments with a sense of belonging, purpose and achievement wouldcarol create a more fulfilling place to work and study[13]. While supporting research into innovative care settings[14] and approaches[15] would also help strengthen the image of social care as an industry that is dynamic and forward thinking.

Workforce and the Adult Social Care Green Paper

Demand for care is increasing, and the trends driving that demand are only set to accelerate and intensify over the next few decades. Indeed, Skills for Care estimate that, by 2030, the care workforce will need to expand by between 31 and 44 per cent (around 500,000 – 700,000 extra jobs)[16]. However it is unclear how Government intends to tackling the existing workforce crisis, let alone plan for the future.

Health Education England’s draft workforce strategy has a long way to go if it is to have an impact in social care. Although the draft strategy acknowledges the challenges in adult social care –  low pay, poor recruitment and retention, lower levels of qualifications to name but a few – it offers little by way of solutions. The strategy will need as much clarity and detail for social care as it does on health. Critically it will need to identify appropriate levers and mechanisms for rolling out a national improvement strategy across a fragmented market and for a largely unregistered workforce.

We also hold the strong view that the draft workforce strategy needs to give much greater consideration to new or adapted roles working across both health and social care. Both the NHS and adult care sector face acute workforce shortages and skills gaps. These will take time to fill. We therefore need to make the most of our existing skills base by thinking more innovatively about job roles and skill mix in teams. We should furthermore take the opportunity to focus on designing roles for the future, ones that support a much more integrated and person-centred approach across health and care, rather than working within the conventions of the past. 

The forthcoming Green Paper will need to provide the means for Health Education England to achieve this. Its primary job must be to ensure the care system is set on sustainable footing for the future. This means tackling the immediate crisis while also putting in place a durable funding solution. Without this, there will continue to be little incentive for providers or local authorities to engage with a long term strategy for their workforce, and not much point trying to persuade people that care is an attractive career option.

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