In February 2018 the National Audit Office (NAO) published ‘The adult social care workforce in England’ . This was a wide ranging report with key conclusions which included that the Department of Health and Social Care was not doing enough to support a sustainable social care workforce, the number of people working in care was not meeting the country’s growing care demands and unmet care needs were increasing. Sir Amyas Morse, Head of the National Audit Office summarised the position at the time of reporting as follows,
“Social care cannot continue as a Cinderella service – without a valued and rewarded workforce, adult social care cannot fulfil its crucial role of supporting elderly and vulnerable people in society.”
Both prior to and following the publication of the NAO report, ADASS had responded to the national ‘Facing the Facts, Shaping the Future’ consultation, had provided evidence to a Public Accounts Committee and a Health and Social Care Committee Inquiry all on the subject of the adult social care workforce . There is cross sector consensus about what the issues are yet the proposed national workforce strategy and the Governments adult social care Green Paper are still awaited whilst the NHS Long Term Plan has been published with additional funding guaranteed to support its delivery.
Whilst this void remains in terms of the future of adult social care, ADASS has committed to sharing its thoughts on how issues surrounding the adult social care workforce could be addressed. Without the commitment of sustainable funding for the sector and the guidance of a green paper this think piece doesn’t address all the issues and can’t provide all of the solutions. However, what we can do is to start the conversation about how we move forward and to build towards a consensus about what is achievable. Includes are potential areas which ADASS would want to see explored in the Governments Green Paper for the future of adult social care. It also includes proposals and challenges for what ADASS, its members and partners can do to make progress.
Following the ADASS Spring Seminar we ask that ADASS regions consider the content of this report and feedback their thoughts and contributions for a future debate via their regional Director lead for workforce.
2) What do people needing care and support want from the Workforce to Live good lives and die good deaths?
Whilst there will be debate about how change can be delivered, what is agreed is that is needed. It is shameful that care is often viewed and referred to as low skilled when it requires commitment, dedication, skill, compassion and resilience. We must not confuse low pay with low skill in an increasingly complex working environment.
In our future statement for the social care workforce we need to be realistic about what we can achieve but at the same time be ambitious for the sector and its workforce. Most importantly we need to consistently remind ourselves and others (Government, the public and the media) that a highly skilled, motivated, appropriately remunerated and appreciated workforce is a key component in supporting people to live safe, well and fulfilling lives.
As well as working out how we can work with the resources we have in terms of workforce, we also need to be ambitious and work with individuals and communities, building engagement and assets. We need to refocus on attracting a range of people into the social care workforce which is representative of society and recruit through values based assessment.
3) Adult social care is ‘Good’ for the economy
The adult social care sector in England was estimated to contribute £38.5 billion to the economy. There are a total of 1.6million jobs (1.13 million full time equivalent roles) and1.47 million people working in social care in England. The indirect effect of the adult social care sector (resulting from the purchase of intermediate goods and services by the adult social care sector in delivering its services) was estimated to contribute a further 603,500 jobs across the UK.
Adult social care, either directly or indirectly, is a large scale employer and it is positive for the economy. It is a growing sector with projections of a further 500,000 jobs being created by 2035. Despite this, the political conversation remains as a one of managing the cost of adult social care. We need to change this and talk about the sector more positively so it is valued in a different way. The challenge to ADASS and its members is to evidence and promote with Government, our own local authorities and our national and local strategic partners (e.g LEPs, employers, universities, colleges) to promote what adult social care offers and what it generates for the economy rather than focussing upon what it costs?
We also need to articulate in a way we haven’t previously the gender issues associated with care – care for family members and care as a career. In general terms the gender pay gap is not closing, more women, particularly in middle age, are giving up work to care, our workforce at the front line is predominantly female. This impacts on women’s health and economic wellbeing, on families, communities and the economy. Giving up work to care for a loved one should be a choice and not a decision which a carer feels they have to make.
Employers being responsive and understanding to the role of carers can make the difference to carers remaining in employment. Local authorities as large scale employers can play a leading role in ensuring that human resources policies and procedures support carers to remain in work whilst continuing in their caring role. In the first instance can ADASS with the national ADASS Carers Network promote the benefits of carers employment rights within local authorities.
4) The resources to recruit and retain a sufficient, skilled workforce
As well as being realistic about how social care can eke out, invent, transform and collaborate, we also need to be ambitious and realistic about cost. The Migration Advisory Committee was to the point in its comments: the social care workforce is not an issue of immigration it is an issue of not paying the workforce enough. What would it cost to pay care staff £30k per annum? Why are care staff not paid enough on one job to feed their families have a roof over their heads in some parts of the country? Housing and housing costs are part of this.
2018 saw the launch of the national adult social care recruitment campaign to address the chronic workforce shortages in adult social care. The campaign focusses on promoting a more positive image of the sector by demonstrating the roles and opportunities available. This is important as when we talk about the social care workforce the conversation can be drawn towards direct care staff. However, social care offers a range of opportunities (e.g. Social Work, Occupational Therapy, Nursing) so when we discuss the challenges and opportunities in the sector we must think about the wider workforce.
The recruitment campaign has galvanised cross sector support, input and involvement and there has been a genuine desire to make it successful. With limited resources and a reduced planning and delivery period the campaign has proved valuable in terms of raising the profile of the sector. We await the project evaluation to see evidence of this engagement translating into more people entering employment in the sector.
Initially funded for a national campaign of only three to four months to close it now would be extremely premature. The success of a national campaign in a sector which has faced workforce shortages for many years cannot be fully evaluated after such a short period of time. To close the campaign now would be another example of short term funding and a short term fix for the adult social care sector. It risks the loss of any momentum gained, further damaging the image of the sector. It would also prevent the learning for the campaign to be utlised to improve and develop it going forward to make lasting changes.
In much the same way that teaching and the armed forces have benefitted from long term campaign support ADASS (with sector partners) will continue to push for a long term financially sustainable national adult social care recruitment campaign in 2019/20 and beyond. It is also important that we continue to make the case for a return to the original proposals of this being a national campaign delivered locally. Only by building upon local and regional resources and by making best use of local knowledge and intelligence of the market can we look to ensure that the limited resources which are available are targeted in the best way for maximum impact.
5) Celebrating success
Regardless of rates of pay many people do not view adult social care as a career of choice. For some adult social care is not an option as it is viewed as low paid, low skilled work with limited career opportunities. The national adult social care recruitment campaign is the start of building an improved image of the sector and the opportunities it offers, but can we do more? We must debunk the myth that there are no career opportunities in the sector. ADASS membership alone proves that there is a career progression route from the front line of social work, social care or related careers. We are evidence of good careers! The same can be said of other key national organisations in the sector.
Too often the work of the social care workforce is overshadowed by those working in the NHS. An example being the promotional work which accompanied the 70th birthday of the NHS at a time when adult social care also celebrated the same landmark. Whilst we don’t want to diminish the achievements of NHS counterparts we need to aim for parity of esteem. Can we work with our partners to develop a communications or promotional approach which recognises and promotes the tireless work, effort and achievements of a skilled, caring and committed workforce so we can have a more positive debate about recruitment and retention.
Working with our partners both nationally and locally we can do more to celebrate the success of the adult social care workforce, to reinforce the importance and value of the roles and to raise the profile of the sector.
6) Be realistic and embrace new ways of working
We know that demand upon social care support is increasing and with this brings an increased demand for improvement recruitment and retention in the sector. Whilst accepting that we need to recruit staff both now and longer term we also need to realistic about what is realistic and achievable. Projections suggest that as we move into the future one in six workers will need to be employed in the health and social care sector to meet rising demand. We have to be honest and ask the question whether that is realistically achievable or even viable for the economy.
Whilst we continue to seek ways to encourage more people to enter the care workforce we also need to be just as active in exploring new and creative ways to reduce the need for so many workers. Technology can never and will never replace all aspects of social care and what we value most about our workforce. However, unless we publically accept and actively promote the use of technology and new models of care we are participating in the creation of potentially an unsustainable long term care and support model.
Can we challenge ourselves to ask if technology really is embedded in our thinking as a whole sector – do we too often default to using people, when there aren’t enough people to be had? We ask that people contribute to the technology work stream of the ADASS Next Generation work where these issues are being discussed.
7) Creating and strengthening partnerships
In recognition of shared concerns ADASS co-Chaired a roundtable discussion with the Royal College of Nursing on the subject of residential care nursing in April 2019. With several other organisations in attendance agreement was reached in a number of areas which collectively as a partnership we will take forward.
This position statement consistently refers to working in partnership. Whilst ADASS remains the leaders for social care the breadth of organisations which are stakeholders in this subject area is extensive. The example given with the Royal College of Nursing is a model we should be pursing to a greater extent with other organisations (the VCS, housing, CJS, Police, Think Tanks) to create partnerships with a stronger collective unified voice.
With this do we also need to remind ourselves that across the country ADASS members are creating and innovating to find solutions to the challenges posed by workforce shortages. Can ADASS members and regions re-commit themselves to greater sharing of practice and experience via the national ADASS Workforce Network and can we find better ways to communicate this out with the wider membership?
8) A salaried workforce
An overstretched workforce, with insufficient training and career opportunities means that the psychological reward of caring for people is greatly diminished. The low remuneration of care workers means that many cannot afford to live in some parts of the country or in decent quality accommodation. Suitable accommodation isn’t just an issue for people receiving services but for the social care workforce as well.
People choose to enter different careers for a variety of reasons and financial reward is not the only factor for many people when choosing a profession. However, financial remuneration needs to be a fair recognition of the skills, knowledge, experience and capabilities which someone possesses. It also needs to reflect the often challenging nature of the roles. For large sections of the adult social care workforce this is not the case. Turnover within the sector remains high at over 30% and whilst pay is not the only factor it has to be an important consideration with staff moving to alternative providers or sectors offering slightly higher rates. High vacancies and turnover is not good for providers who need to turn to agency staff at higher rates. More importantly high vacancies and turnover is not good for the people we support who value consistency and long term relationships.
If we want to aim high and to be ambitious for care staff we need to see salaried roles which offer people security and a fair wage which reflects the often challenging roles they have. We need to move on from a conversation about national minimum or living wage jobs. The only way we can achieve this is via a long term sustainable financial solution for adult social care with local practices which reward providers for investing in their staff.
9) Incentives to work in the sector – training, development and career progression (greater parity with the NHS)
In addition to salaries another way in which we can look to attract and retain people in the sector is by promoting different entrance routes into the profession, (apprenticeships) training, career pathways and progression opportunities. Training and development of the adult social care workforce cannot be viewed in separation from the future plans for sustainable health and social care systems in the NHS Long Term Plan.
We recognise the need to make the sector an attractive option for the people with the skills, qualities and potential we need. Longer term retention and career progression can in turn lead to higher salaries. Research by Skills for Care demonstrates that where investment is made in staff learning and development 94% of providers reported it had a positive impact upon retention. There are several areas which can begin to bring about the changes required:
• We would welcome further work to support mandatory training in the 'care certificate' as a basic minimum alongside registration for unit managers in both home care and residential settings – as the CQC have stated – 'well led' will typically mean 'safe'.
• Career pathways and opportunities that lead to a range of options including social work, nursing, therapies, community development, employment support or other professions.
• Joint training and qualifications for those providing personal care and nursing for those of us with very complex needs.
Whilst accepting that these are things we can and should be doing, we also need to recognise that for many providers the costs can seem to be prohibitive, particularly when turnover in the sector is so high. There is also a sense that often social care is training and preparing staff who then ultimately move into careers in the NHS because of the pay, terms and conditions and opportunities which are on offer. Will we begin to see traditional social care roles evolve further as closer working with the NHS brings health and care staff together? Is this an open conversation we need to be having now?
We therefore have to be honest and open about the disparity between the NHS and the social care workforce which is clearly demonstrated when comparing the funding of Skills for Care and Health Education England. The annual budget for Skills for Care is approximately £29million whereas it is over £4.5billion for Health Education England.
Whilst accepting that Health Education England has responsibility for funding some expensive medical qualifications the disparity cannot be explained by that alone. The funding available to Skills for Care is equivalent to just £14 per person working in the sector. If we want to see longer term retention in social care which in turn will support sustainable health and social care systems then we need a greater degree of parity with the NHS and this is an area which needs to be addressed in a future national workforce strategy.
At a regional level can we do more in engaging with HEE to see training resources being made available to the social care sector? Whilst we need to promote adult social care as a career in its own right greater funding or access to HEE training or resources would recognise the inevitable close connection. ICS or STP may be the most appropriate level to have these conversations but the sector needs to have a unified voice in these discussions.
In November 2018 the Kings Fund published ‘The health care workforce in England: make or break?’ Whilst reflecting upon some of the challenges in social care the report largely focused upon the health care workforce.
Included in the publication were five key tests for the NHS long-term plan and supporting workforce strategies. In reality these are the same questions we should be posing in regards to a future Green Paper, hopefully this conversation piece has given us the areas where we need to base our conversations in the future.
Test 1: Is there a funded and credible strategy to address the immediate workforce shortages – including addressing forecast shortages in job specialties and specific geographic areas?
Test 2: Is there a funded and credible long-term strategy to deliver a sustainable workforce over the next 10 years?
Test 3: Is there a funded and credible strategy to support new ways of working across the health care workforce?
Test 4: Is there a credible strategy for addressing inequalities in recruitment, pay and career progression by gender, ethnicity and occupation?
Test 5: Is there a plan to strengthen workforce and service planning at all levels of the system, including alignment of the institutional accountabilities and responsibilities for these?
As previously noted this document is intended to be the start of a conversation, not the end. It acknowledges the challenges the sector faces and the fact that there is no single solution. What is agreed is the current system is not sustainable in the long term and something needs to change. This change needs to be driven by the experts in the sector and we have a louder voice if this is done in partnership as we shape what is required from a national adult social care workforce strategy.