For older people in particular, there is an increasingly fine line between social care and health care. As we reported at the end of 2017, the two systems need to work closely together if they are to maximise health and quality of life. A key aspect of this is the need for an equal partnership, rather than seeing social care as the junior partner. After all, in a typical nursing home, nurses and care assistants develop a particular expertise in how they manage a wide range of complex health needs, which deserves recognition.
In its most recent report on the social care workforce, the National Audit Office (NAO) strongly echoes this message about respecting the roles of care home and home care staff. The report sets out how a high turnover of staff and difficulties in filling vacancies mean that for several 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. And many providers are struggling to remain viable: witness the recent difficulties of even a large corporate group such as Four Seasons.
The NAO asks, at a system level, who’s in charge of overseeing the social care workforce and setting a strategy to manage this growing level of risk? No one, it seems. Providers (almost all of whom are in the private sector) may be managing risk at the level of individual services, but at system level the NAO concludes that the Department of Health and Social Care is ‘not doing enough’ and local authorities are fire-fighting, with insufficient capacity for a more strategic approach.
So how could we take a more strategic approach to developing the social care workforce, which fits with the move towards integrated care? Here are two starting points.
First, we need to stop considering health and social care workforces separately. Good (and efficient) care for people requires the two to work together, and it makes sense to join up arrangements and responsibilities for overseeing both. As local areas increasingly integrate services around the individual’s needs, the knock-on implications for how practice and roles will change, and what training will be needed, cross both health and social care. There are common challenges, 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.
Second, we need some vision. A Green Paper on social care is already promised for later this year, as is a national strategy for the health and care workforce – although the draft currently out for consultation is worryingly thin on detail about the social care workforce and does not address the challenges and opportunities of developing the workforce for health and care as one integrated system. 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.
With more than 20,000 providers (each with their own workforce policies), huge numbers (1.34 million employees, or half as many again as the NHS in England) and growing demand (but lack of capacity and stability in the market to respond), the scale of the challenge for policy on social care workforce can feel daunting. Many of the problems set out by the NAO are not new and make clear a history of issues languishing in the ‘too difficult’ box – often, no doubt, because solutions such as more staff or more training for staff, cost money that simply has not been available to local authorities. There are resources, such as those from Skills for Care, which could be scaled up and joined up with NHS workforce development, and with the plan to develop a single national workforce strategy there is now a greater recognition of the importance of the workforce and more political acknowledgement of the need to grasp issues than there has been in recent years.
That is encouraging but not enough: the proof will be in the pudding. How far will the workforce strategy and political support extend to social care? Will it be enough to unblock this complex and challenged area of policy?
So many reports and comments repeating the same message - integration, connection and real commitment to addressing the workforce challenges as a priority for H&SC - dare I say observed most often from the safe distance of those who don't have direct responsibility for care and service delivery.
For us who essentially live and breathe the day to day lives of those that live and work in care homes for example the critical elements must include some of the following:
- culture, belief, positive attitudes, enthusiasm and how we enhance the status and image of care work
- embedding kindness and pride in the work that we do in doing the right things well and having a great time doing it!
- making sure we can tackle to sizable industry of negative press, blame and accusing fingers with no understanding of the pressures impacting upon the care sector dealing with what for some time I have been describing as the 'perfect storm' of increased demand, workforce challenges, increased expectation and scrutiny, rising and escalating running costs, and an ageing population with complex needs and multiple co morbidities coming to 24/7 much much later often in a poor state as a result of inadequate care package support at home.
I say all of this perversely from a position of relative strength and optimism - my 2 care homes have really excellent CQC ratings, are always popular with full occupancy and really amazing well established staff teams - exemplified by the heroics of fantastic commitment during last week's snowmaggedon! Yet unless we combine our efforts and energies from likeminded 'in it together' planning and more importantly action the system will crumble for sure - all the optimism and belief in the world won't stave of the consequences of 'beyond the tipping point'
The KF have acted as a keen and objective commentator of the year upon year of saying things and setting out good intention without action sadly - the Green Paper many will feel to be yet another in the long list of posturing and procrastinating on the urgency of a real solution to the needs of the vulnerable. We have furnished many with credible, constructive and creative ideas to add to the need for courage and clarity on care provision - even as recently as 2 wks ago we responded through a request from one of our highly active local MPs to support a response to the series of NAO and Health Foundation reports on workforce in social care. This was to assist one of the many parliamentary select committee debates taking place. We do remain hopeful that the Green Paper will be braver and adhere more to the methodology we are guided by when inspected by the Care Quality Commission with its 5 key questions - are we Safe, Caring, Effective, Responsive to Need and Well Led? - this format can and should be used in monitoring the success and impact of the Green Paper and this Government regarding health and social care. I truly hope, like my care homes, we can rate their impact as Outstanding in the not too distant future
Thanks for a really useful and stimulating piece by the way
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