Written evidence from the King’s Fund

Key points:

• The social care workforce is facing a huge challenge looking forward – the sector will need between 350,000 and 700,000 more workers by 2030. This is against a background in which in recent years the workforce has not kept pace with increasing demand for social care.
• The rates that local authorities pay for publicly-funded care home places are around £1bn below the rates required by the sector to operate at a sustainable level, with inevitable consequences for the pay and conditions of staff.
• The draft Health Education England health and care strategy makes welcome reference to the importance of the social care system in its own right, but does not go far enough in developing a strategy for how the two systems can be joined up. We urgently need further development, analysis and recommendations on how to integrate the two systems if this strategy is to take into account the needs of the social care workforce and people who rely on the system into the future.

Q1.     What are consequences of high vacancy and turnover rates across the adult social care workforce?

Some of the consequences are:

• Discontinuity of care when service users are cared for by different staff and are therefore unable to build up a relationship with a specific client (which can be particularly important e.g. to people with dementia)
• Quality of care, when staff do not have time to engage with service users in a meaningful way because they are rushing from one job to another in domiciliary care or have too low staff/resident ratios in residential care.
• Extra pressure on existing staff either in terms of staff resident ratios in care homes for specific shifts or pressure put on care staff to work more shifts than they want, on days they don’t want to work or when they are ill or otherwise unable to work.
• Extra cost and management time for providers in recruitment.

Q2.     What needs to be done to improve recruitment and retention rates?

• It needs to be recognised that, at least for home care, there may be a significant difference between local areas in terms of recruitment and retention. Our forthcoming work on home care commissioning suggests that availability of workforce supply varies depending on the demographics of local areas with differences often between some urban areas, where a large pool of available labour means home care companies can find it easier to recruit, and some rural areas. Recruitment and retention strategies need to recognise these very significant local differences.
• There are a wide range of job roles within adult social care, with differing vacancy rates and – potentially – differing reasons for recruitment and retention rates. The three of greatest concern are care workers (33.8% turnover); registered nurses (32.1%) and registered managers (23%).  While the registered manager vacancy rate is lower than the others, it is critical because the existence of a registered manager in a care home has a strong correlation to overall CQC quality. However, the reasons for high vacancy rate of managers may not be the same as for those nurses in nursing homes where there is more potential for staff to move to nursing roles in other sectors, most obviously the NHS.
• Some employers report that an approach to recruitment that emphasise an individual’s values rather than their pre-existing work experience  is a successful approach but it may be necessary to understand its impact on the wider market for social care workforce in a particular area i.e. does it widen the total pool of workers by attaching people into social care who might otherwise not have joined the sector or merely move the existing workforce around within a local social care economy?
• There is significant difference between employers in terms of retention rates. Skills for Care estimates that around a quarter of employers have lower than 10% annual turnover rates and has provided advice from successful employers that may be used more widely. It will be important to understand to what extent turnover rate relates to the characteristics of employers or driven by circumstances outside of their control such as local workforce demographics.
• Pay and conditions are fundamental. Skills for Care notes that while only 3% of leavers cite pay as being their reason for leaving, other cited factors such as career development or transfer to another employer may also be influenced by pay. Not only is the average pay of a care worker barely above the minimum wage, the Kingsmill Review found that many care workers were being paid below this level. The rate of pay is also, in at least some areas, below that of competing labour sectors such as retail. Furthermore, a review by Skills for Care in 2016 suggested that around a quarter of the workforce is on zero hours contracts, including nearly half of workers in home care services.

Q3.        What can be done to boost the image of working in care?

• It would be helpful if there was more public awareness of the scale of the social care workforce and its critical importance in ensuring the dignity, comfort and independence of those with social care needs. The public – and particularly those most likely to consider a role in care – also need to have a better understanding of the very high levels of job satisfaction of many people working in care.

• Pay remains a fundamental issue. If staff are paid less to work in care than in retail or food outlets then there is an understandable knock-on effect on the value that people place on care work.

Q4.        How should training and development of the care workforce improve?

• There is potential for greater sharing of skills between NHS and social care locally, and for career development opportunities. As we reported at the end of 2017, health and social care need to work closely together if they are to maximise health and quality of life. However, a key aspect of this is the need for an equal partnership, rather than seeing social care as the junior partner.
• Training and development needs to reflect changing local practice, whether that is a result of changes to the level of services provided, strategic plans for greater integration of services or some other factor. For example, in our examination of the role and capacity of district nurses, we heard evidence of some low level clinical tasks being built into the work of care workers. While some commissioners saw this as a positive step (and from patient/service user perspective it may have advantages in reducing the number of separate contacts required with health and care services), providers were concerned about the practicalities of how this level of care could be achieved, particularly given the short times available for each call. This also creates the additional financial burden of having to train staff in wider health roles, which could be particularly onerous for businesses who have high turnover of staff.
• There are common challenges between health and social care, such as the need to improve data about the workforce. And there could be shared benefits if there was better co-ordinated planning for educating and recruiting those who will work in health and care in the future. To do this, there needs to be much more clarity about what should be the responsibility of providers, including private providers; what should be done at local system level; and what national bodies should do – looking across both the health and social care workforces. Pinning down these different roles and responsibilities at each level, and accountability for them, would be a big step forward.

Q5.     From a workforce perspective, what do you want to see in the green paper on care for older adults? 

• Market sustainability remains a key issue for social care and issues about sustainability of providers must be addressed. As the recent CMA report on care homes identified, the rates that local authorities pay for publicly-funded care home places are around £1bn below the rates required by the sector to operate at a sustainable level. This under-payment has inevitable consequences for the pay and conditions of the social care workforce.  
• The green paper needs to recognise and address the scale of the recruitment challenge facing social care. Skills for Care estimates that demand for workers will increase by between 21% (equating to 350,000 jobs) and 44% (equating to 700,000 jobs) by 2030. This is against a background in which in recent years the workforce has not kept pace with increasing demand for social care. Unless action is taken, the future looks even bleaker. Brexit could hit social care particularly hard (because, according to the NAO, in some local authority areas more than one in five people working in social care come from other EU countries) unless a way is found for future immigration policy to recognise the importance of overseas recruitment for the social care workforce.
• The Green Paper and the final strategy should both take a broad view and avoid seeing workforce policy only in terms of filling vacancies. They should set out the narrative for developing a workforce that can consistently deliver high-quality care: one in which social care is somewhere that people want to work because it fits with their values and their family life, they get a sense of achievement, and they are supported and stretched to do their best. Leadership in provider organisations is central to achieving that, but is not the whole story. Local and national system leaders need to step up too, to create the right conditions and set expectations.

Q6.     What were your impressions of the draft Health Education England health and care strategy?

• We welcome the explicit recognition in the draft HEE strategy that ’the social care system is not simply a mechanism to ease pressure on health services, but it is a vital system in its own right and that the framing of national and local NHS workforce policy and systems equally needs to consider how it can best contribute to the success of social care workforce policy’.
• We also welcome the statement that ‘workforce planning and education and training systems will need to meet the needs of both sectors and policy makers in both parts of the health and care system will need to work together to ensure that success in recruiting and retain key staff in one sector does not drain much needed staff from the other.”
• However, it was very disappointing that the draft strategy did not develop these statements or provide further analysis, thought or recommendations on how they might be taken forward. This was essentially a document about the health care system, particularly the NHS, into which a very short (4 pages in a 142-page report) section about the social care workforce and a small number of other statements or references had been added. It was in no sense a strategy which considered how to coordinate or join up approaches to the two sectors.

Simon Bottery, Senior Fellow at the King’s Fund