People with health and social care needs who live at home should be supported to lead independent and fulfilling lives in accordance with their own wishes. This principle underpins Homecare: delivering personal care and practical support to older people living in their own homes, the NICE guideline which sets out what good homecare should look like.  

It goes without saying that everyone involved in the delivery of care services would like to provide the standard of care and support described in the NICE recommendations, but to do so is so challenging that it is often just not possible. Lack of resources means that many people only have enough care to meet their most basic needs, while others get no care at all, despite their needs.  Living an independent and fulfilling life in accordance with their own wishes must seem like an impossible dream for all but a minority of people who need care - and many of them will be paying for it themselves. Despite frequent and increasingly desperate calls from leaders in the social care sector and the mass exit of care workers to better-paid sectors, the government does not seem to come anywhere near understanding the scale of the problem. Or, it does understand, but is not prepared to provide an adequate level of funding.

Sarah McClinton, President of ADASS, said: “The number of people waiting for care and support continues to grow steeply: now more than a half a million people are missing out on vital care and support.
 
“Social care has been heroic – there has been a very big increase in the number of hours of homecare that have been delivered over recent months, BUT we have seen an even greater jump in the number of hours that could not be delivered because of a lack of capacity.   Putting this right is vital for people waiting for care and support – without it, carers are having to take paid or unpaid leave from work or people are getting worse and ending up in hospital. That doesn’t make any sense and creates a vicious cycle.”

Lack of funding, and the consequent shortage of care workers, is not a new problem in social care. It is a long time since funding kept pace with the rising need for care from an ageing population, but the problem is now worse than it has ever been before. Care workers may enjoy their jobs and find them rewarding, but they can’t afford to work for the low pay rates on offer and the often-unattractive terms and conditions, particularly when the cost of living is rising so steeply. High fuel costs, for example, are a serious problem. Many care workers use their own transport for work and are not fully compensated for their fuel costs. According to research from the Homecare Association, it is not unusual for care workers to receive mileage rates of only 10p a mile. In addition, care workers had a really tough time during the pandemic and often felt unrecognised and unrewarded for the vital contribution that they were making. Some have experienced ‘COVID burnout’. Who could blame care workers for wanting to move out of the sector, particularly when there are job opportunities in other sectors where the pay rates are higher and the responsibility is lower?

Dr Jane Townson, CEO of the Homecare Association said: “Squeezing fee rates over many years has led to poor pay, terms and conditions for care workers. At the same time that demand for homecare is rising, we are experiencing the worst shortage of care workers in living memory. Care workers are leaving in droves to jobs in retail and hospitality, which pay much higher wages.

“We continue to call on central government to provide adequate financial support for local authorities to enable them to pay a fair price for care, allowing care workers to receive wages equivalent to Band 3 healthcare assistants in the NHS with 2+ years’ experience (£11.14 per hour).”

According to a Skills for Care briefing on domiciliary care services in the adult social care sector, the average pay rate for a care worker working for a local authority was £10.61 and for an independent provider £9.44, with care workers in the north earning less than those in the south.  (From 1 April 2021, the National Minimum Wage was £8.91 per hour for workers aged 23 and over.)  The vacancy rate for homecare services was 9.1% in 2020/21, equating to an estimated 53,000 vacancies at any one time. The staff turnover rate was 31.5%, which equates to 166,00 workers leaving or changing their jobs during the period of the survey.  Although 63% of recruits into homecare services have come from roles in adult social care, that still leaves a significant number who will require training. The cost of training on top of the costs of recruitment is an ongoing financial burden on providers.

Ultimately, if care workers leave their jobs to the extent that there aren’t enough staff left in a provider organisation to fulfil contracts, the provider will have no option but to close their service. According to a report from ADASS published in November 2021, the proportion of local authorities reporting homecare provider closures, or providers ceasing to trade, was 41% for the six months preceding the report. For the six months before that the number was 21%. Care home and nursing home closures had also increased during the second period. However, the pandemic might have had an impact on these figures, so it will be a while before we can know if this is a developing trend.

EU immigration

Finding workers from abroad is one possible solution to the recruitment and retention problem. Recruiting care workers from the EU came to an end when the UK left because they weren’t on the skilled worker shortage occupation list. However, following intense pressure from the social care sector, the government accepted recommendations from the Migration Advisory Committee and agreed to add care workers to the list.  From 15 February 2022, care workers from the EU were eligible to apply for a work visa for the UK, providing they could meet a number of specified conditions.

Employing EU nationals is administratively and financially challenging for provider organisations, particularly the smaller ones with fewer resources. In addition to the cost of a mandatory Skilled Worker Sponsor Licence, employers have to pay fees for each employee they take on, meaning that it can cost hundreds of pounds to employ a single worker. People who don’t use agencies, but directly employ their own care workers report that the end of freedom of movement has made it more difficult to find workers to provide their support. Unfortunately, they can’t, apply through the scheme because it is not open to individual employers.

It’s too soon to know how successful the scheme has been as it started so recently and applications for licences can take weeks, if not months, but it is unlikely that it will go a long way towards solving the recruitment crisis. 

In a recent report, The Migration Advisory Committee has made its position very clear on the employment of people from the EU:

“Immigration policy may be able to help alleviate some of the workforce problems that the sector is facing, but it is not the best solution to these problems. The real solution lies well beyond our remit, in the design and funding of the system itself. It would also be highly damaging for the sector in the long term if the necessarily limited and short-term relief brought by immigration policy were used as an ‘excuse’ not to address the more fundamental problems the sector faces.”

In any case, there is surely a limit to the number of care workers that the European Union can supply to the UK. Population growth across Europe is low and people are living longer, but not necessarily healthier, lives. The percentage of people aged 60 plus will go up over the coming decades and the demand for care workers will continue to rise. There is no reason to think that large numbers of them will want to move from their own countries to the UK now that we are no longer part of the EU. In fact, it is likely that both the EU and the UK will be looking further afield for care workers.

Government funding

What measures the government have put in place have been inadequate. Last autumn the Department of Health and Social Care (DHSC) announced a Workforce Recruitment and Retention Fund totalling £162.5 million that was to be used to “support local authorities to address adult social care workforce capacity pressures in their geographical area through recruitment and retention activity” between 21 October and 31 March 2022.

Commenting on the launch of the fund, Dr Townson said: “Whilst the additional money announced will help, it amounts to only £100 per member of the care workforce. This will not be enough to address the poor pay, terms and conditions of employment which limit growth and development of workforce capacity to meet needs.”

The evidence supports her view. There has been no recent improvement in recruitment and retention rates. In fact, the situation seems to be getting worse. Skills for Care’s Vacancy tracking – monthly information for March 2021 - May 2022 shows that across all of the social care sector vacancy rates had risen to 10% across England, and as high as 13.1% in London, whereas they were only 5.9% in March 2021. The data is unweighted but shows a steady rise in vacancies across the year.

In the longer term, or at least for the next three years, the government has promised to provide extra funding for social care through the Health and Social Care levy, which is funded by controversial 1.25% increase in National Insurance that was announced.

The government has great ambitions for the levy: “The levy will reform the social care system, backed by £5.4 billion. It will end spiralling social care costs, provide a limit to the cost of care for everyone in the adult social care system for the first time, and significantly increase state support.”

The government’s plans for improving the rates of pay that local authorities pay providers for care are set out in its Market Sustainability and Fair Cost of Care Fund 2022 to 2023: Guidance. The funding will be distributed using the adult social care relative needs formula and there are conditions attached. Local authorities will have to carry out cost of care exercises, produce market sustainability plans and report spending data – a bureaucratic burden that they could well do without.

Responding to the guidance Cllr David Fothergill, Chair of the LGA’s Community Wellbeing Board, said: “Social care has been facing problems regarding instability and unsustainability within the market for a number of years, and it’s good to see recognition of this from the government with this plan.

“However, we believe that the funding allocated falls far short of needs, and will not fully resource councils and providers in delivering the government’s objectives.

“Adult social care is facing a funding gap for current services, increasing each year due to inflation and other costs even with these reforms fully funded. This is without considering the immediate need to address unmet and under met need on these overburdened systems.”

Impact on NHS

Lack of social care staff doesn’t only affect people who need social care; it also affects people who need NHS care. In March 2022, the average monthly number of patients who were medically fit but were not discharged each day from an NHS hospital was 11,796. Many of these people would have been kept in hospital because they were not able to manage in their own at home but no care package was available. Being stuck in hospital is likely to have a negative impact on a person’s mental and physical health.  Hospital services are badly affected because a lack of beds contributes to extended ambulance waiting times, cancelled clinics and cancelled operations.

Keeping medically fit people in hospital is having a major impact on the effort to get back to normal after the COVID crisis. And, given that the NHS is also struggling with serious staff shortages, there is little hope that the huge backlog of cases will be cleared anytime soon. Whether the government can provide any meaningful help to ease the situation remains to be seen.