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How will the NHS cope if social care fails?

What is happening to the social care workforce, and how can we solve it?

With winter fast approaching, bringing with it a ‘twindemic’ of increasing rates of flu and COVID, the NHS is facing enormous challenges over the next few months.

Hospitals will be looking to discharge those well enough to receive care at home to free up bed space and alleviate pressures. However, the workforce development and planning body Skills for Care, reported that there are currently 165,000 vacant posts in the adult social care sector. The demand for social care is rising but staff shortages leave many people unable to access quality care.

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There have been many conversations surrounding what adult social care needs to get back on its feet, with pay taking up a large proportion of these conversations. However, health researchers believe that the Government and local authorities need to look at the bigger picture when it comes to tackling the issues within social care.

They believe that the sector needs to have long-term changes implemented that do not tinker around the edges but takes into account what providers, staff and receivers of care need in a holistic way.

‘What we need is a fully joined up approach to adult social care,’ said Simon Bottery, senior fellow at health think tank the King’s Fund.

Figures released by Skills for Care found that the social care workforce had shrunk by 50,000 in the last year as vacant posts rose to a record 52%. The decrease in filled posts is due to the sectors inability to recruit and retain its staff.

Recruitment and retention is proving difficult for the sector due to its poor pay conditions. A King’s Fund analysis found that 9 out of 10 major supermarkets in the UK pay their entry level staff more than care workers. It concluded that if 395,000 care workers moved to a supermarket job tomorrow they would be earning more.

‘Frustratingly too many social care providers are forced to pay minimum wage (£9.50 per hour) because of the inadequate rates paid by commissioning bodies be they Local Authorities or NHS organisations,’ said Anita Astle, managing director at Wren Hall, a specialist dementia care nursing home in Nottinghamshire.

Poor pay has had consequences for care workers. Another think tank, the Health Foundation published statistics showing that even before the cost of living crisis hit, one in five residential care workers were living in poverty.

Winter will bring challenges especially with many households worried about how they will pay their heating bills. Therefore, with many workers already struggling, the added stress of the cost of living crisis is encouraging them to leave due to their salaries simply not being enough to support them and their families.

‘As much as many people who work in social care are dedicated to their role there might be a point where it’s no longer lucrative or survivable to stay in social care,’ said Camille Oung, researcher at the think tank Nuffield Trust.

It is not just care workers leaving the sector, registered nurses are leaving as well. Skills for Care published in a report that between 2012/13 and 2019/20 registered nurse jobs decreased from 51,000 to 34,000. They related this decrease to the recruitment and retention problem facing many employers which is why investment for better pay packages is vital to keep the sector afloat.

Poor pay packages led to the Royal College of Nursing (RCN) holding a ballot for strike action, in October for the first time in its history. The majority of members voted in favour and will be walking out this December as many nurses feel they are not being pair fairly.

Chief executive of the RCN, Pat Cullen responded to the results saying, ‘Anger has become action, our members are saying enough is enough. The voice of nursing in the UK is strong and I will make sure it is heard. Our members will no longer tolerate a financial knife-edge and a raw deal at work.’

Increasing pay in the sector will be a starting point to make a career in social care desirable. However, Mr Bottery pointed out that there are other crucial things that need to be introduced to increase recruitment and retention.

‘There needs to be some sense that people will progress in an adult social care role in terms of their skills and knowledge and learning but also what they earn,’ he said.

Setting up frameworks that will provide clear pathways to career progression will help to retain staff. Skills for Care reported that the difference in pay in the sector between someone who has just started versus someone who has been working for five years was only 7p per hour.

Miss Oung said ‘there needs to be thought given to what a career progression in social care might look like, how there might be different specialisation opportunities such as dementia pathways or integrated care pathways.’

The skills that experienced staff have are not being appreciated and reflected in their earnings. While new recruits lack opportunities to build clear career specialisations.

The lack of opportunity to progress and develop a career in social care comes from the fact that the sector overall is underfunded.

The King’s Fund carried out analysis last year that found the social care system to be under-resourced as local authority budgets have failed to keep pace with the demand of care increasing. They found that total spending by local authorities on adult social care had only increased by £100 million in a decade.

This underfunding of the sector restricts the eligibility of people to receive publicly funded care.

‘At the moment we’re raising money and spending it on people with the highest needs and lowest assets and people who fall outside of those criteria have to either pay for themselves or they rely on family and friends or they go without’ said Mr Bottery.

The King’s Fund also reported that 1 in 10 people will end up spending over £100,000 on care out of their own pockets.

‘I think there’s a real need to increase the number of people who are eligible for publicly funded support by providing services to people with lower levels of need but also its particularly about making sure the current very stringent means test is relaxed’ added Mr Bottery.


To tackle these issues the government has introduced policies that will be implemented in October 2023. There will be an instruction of an £86,000 cap on costs for those who are paying for their care and the means test is being relaxed to allow more people to be eligible for publicly funded care.

Anita Astle believed that one solution to alleviating pressures on social care could be both NHS and local authorities working together with social care as equal partners. Currently, many local authorities pay providers less than they need to deliver quality care.

‘Organisations that are providing care are leaving the sector because it’s no longer sustainable for them to work in social care and so that means those remaining providers they’re only able to focus on the most essential care’ said Miss Oung.

Focusing only on essential care impacts the lives of those who need it. Charity Alzheimer’s Society revealed how care workers are only able to carry out 15 minute home visits due to the lack of staffing. This ultimately prevents workers from giving people the best care possible.

Having local authorities and independent providers work together could help to bridge the gap between both areas and allow funding to be distributed more equally, allowing those working for independent providers to be paid more.

As Skills for Care examined the hourly pay difference between the local authority and independent sector across all jobs in social care. They found that overall pay rates were higher for local authority workers across all professions in social care compared to independent sector employees.

For example, the mean hourly rate for an independent sector registered nurse is £18.23 while a local authority sector nurse earns £18.81 an hour. While the gap is only 58p an hour, this can equate to a £1055.60 difference in annual pay. This degree of pay differential within the sector shows why workers are leaving the independent sector when they see their local authority counterparts are earning more.

These figures show the funding gap that is occurring across the social care system specifically between local authorities and independent providers. This issue is a catalyst for staffing shortages in social care, workers are leaving their posts because providers cannot compete with what local authorities or even other job sectors are paying people.

The idea of collaborative working as mentioned by Mrs Astle is currently being explored through integrated care systems (ICS). Their purpose is to bring partner organisations together to plan and deliver joined up health and care services. As of July 2022, 42 ICSs were established across England.

Both the King’s Fund and Nuffield Trust believe that ICSs have a really important part to play in providing more collaborative opportunities between health and social care to help improve the functioning of the care system.

‘What we need to do is to get to a position where integrated care systems recognise that social care isn’t simply about local authorities. They need to realise that actually the social care provision is with the independent sector and those providers have tended not to be involved in ICSs,’ said Mr Bottery.

The Nuffield Trust have been looking at the ICS model in Scotland. The country initially had joint working budgets which hadn’t shifted from hospitals out into the community, so Scotland is now reforming and reorganizing their ICSs around only community health and social care, so that acute care will be its own funding stream.

‘We need to think about more joined up pathways that go between health and social care, thinking about more opportunities of building roles such as associated nurses and roles that could bridge the gap more easily. Potentially taking away that competitiveness between different parts of the sector’ suggested researcher at Nuffield Trust, Miss Oung.

However, Simon Bottery suggests that the work of social care is sometimes purely seen through an NHS lens. ‘It’s seen as a sort of way of relieving NHS problems but social care has value in its own right in terms of promoting well-being and independence it’s not simply about making the health care system more efficient.’

Therefore, having a collaborative approach between health and social care has the potential to work well if the collaborative working takes into account what social care truly needs so that it can develop in its own right rather than implementing changes that will help social care to support health care better.

‘As a society we don’t tend to see social care workers as being a particularly skilled area of work’ said Mr Bottery.

‘We need to recognise the skills set the care workers have, but also trying as a society to elevate that skillset.’

The Nuffield Trust has examined Germany and Japan who were successful in reforming their social care systems. Although it is important to note the context that these reforms were done in, and cannot be directly replicated in England. There are key features of those reforms that could be used to model new policy in England. Miss Oung suggests having political and public leadership to make sure that there is someone at the top really driving an ideal can be useful in helping to make changes around social care.

The suggestion here is that if there can be strong leadership driving the importance of a stable social care system that takes into account its value and what it brings to the table for society, this could help it to change for the better. Alongside giving a voice to all of those involved in social care and providing them with what they need to carry out their jobs properly so that social care can work alongside local authorities and the NHS to support each other. However, it is up to policy makers to now grasp this nettle.

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