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11 / Why reform matters to everybody, not just home care workers

Updated: Sep 9, 2023

Chronic underfunding and poor employment conditions mean people in England who need social care are already affected by poor quality and availability of care, in addition to care itself representing a huge ongoing cost if the individual has to fund it themselves.

Yet the scale of the problem is only set to balloon over coming years, as more and more of the population end up in need of social care. This will affect us all. Even if you are lucky enough not to need social care yourself in the future, it is almost inevitable that a loved one will.

Rising demand for care

According to figures produced for the Department of Health and Social Care, there will be a 41% rise in the number of people aged 65 and over by 2038 (compared to 2018) and a 72% rise in the number of people over the age of 85 (Hu, Hancock and Wittenberg, 2020, p.5). Just let that sink in. 72% more people in the oldest age bracket.

"The number of people who are over 85 is rising faster than any other segment of the population. This is the group of people who are most likely to need some sort of daily assistance to carry out ‘normal’ activities. They need care" (Koehler, 2014, p.13)

Alongside the rising number of older people, will be an increase in the number of people living with chronic health conditions, plus a decrease in the amount of care provided unpaid by family members. After all, many women who in the past would have assumed caring responsibilities now have careers, and it is common for people to live far away from their parents.

As a result, demand for formal, paid social care services has never been greater and will become greater still. The number of people who need home care funded by their local authority is expected to rise by 61% between 2018 and 2038 and by 56% for those who fund their own care (Hu, Hancock and Wittenberg, 2020, p.5).

The social care workforce urgently needs to grow in order to keep up with demand. Yet the sector is in the midst of a long-term recruitment and retention crisis: the polar opposite of where we need to be. To put the scale of the recruitment challenge into perspective:

“Estimates suggest that if the adult social care workforce is to grow proportionally to the number of people aged over 65, 580,000 more social care jobs will be required by 2035. If it is to grow proportionally to the number of people aged over 75, this figure would rise to 800,000 jobs” (Health and Social Care Committee, 2020, p.16)

The government's current strategy to try to expand the social care workforce has been to grant thousands of working visas to people from overseas on the condition that they work in care (GOV.UK, 2023a ; GOV.UK, 2023b). This locks the issues around employment conditions and quality of care in place. Read more here.

Impacts on quality of care

The way care work is currently organised, alongside chronic staff shortages, means the quality of social care you can expect to receive is in question. Have a read of the following account from a home care worker about what a typical care visit involves and ask yourself: is this what you would want for yourself or a loved one?:

"When you are in a client's house you are constantly looking at the time. Sometimes you are going to see people, who to be honest are complete strangers. You haven't got time to sit there and read their care plans because by the time you do it, you've wasted 10-15 minutes. You've got 15 minutes left then to do everything and it's diabolical. All that is going through my mind is, 'Right, I've got half an hour to get out of here because I am not paid to go over my time'. It's like saying to yourself, 'Right Ethel, I've got to get you in here; washed, dressed, out again; put drugs in you, whip the hoover round and get out.' When you start rushing a job you can make mistakes. If mistakes happen when you are looking after someone, then it will all come down on you. You are so worried about that, you forget that Nelly hasn't had no dinner. Rushing around you are bound to forget things sometimes because you've got so much on. You're meant to empty bins, do their beds and all that, but you have to cut corners. You can't hang around and have to say 'look, I'm in a rush'" (Hayes, 2017, p.73)

It is through no fault of care workers themselves that the way their work is organised makes it impossible to deliver the highest quality of care, as above. Many care workers go above and beyond, working unpaid to meet the needs of their clients.

The issues facing social care go so far as to threaten the human rights of older people:

"The Equality and Human rights Commission (EHrC) carried out a review of home care and found that the low pay and status of care workers, coupled with high workforce turnover rates, was a significant factor exacerbating threats to the human rights of older people" (Koehler, 2014, p.20)

Another factor which impacts quality of care is how easy it currently is to get a job as a care worker:

"While it takes a lot to be a good care worker, it does not take much to join the workforce. All a prospective care worker needs is a means of transport, a means of contact and a criminal records check. There is an aspiration to pursue ‘values-based’ recruitment – because in much care work the right attitude and kindness are more important than qualifications. This is not easy work, so people who want to care for others are considered less likely to move on quickly. But the reality of a high turnover, high demand but low paid recruitment market means that values often cannot be recruited for. Even if a care worker was found to be too unskilled or too uncaring to continue working with a company there is little to stop them from seeking work with another care provider" (Koehler, 2014, p.19)

Worryingly, the nature of home care work means it is easy for poor practice to fall under the radar:

"If there has not been the level of scandal in the domiciliary care sector, it may be partly because care workers often work alone in the privacy of people’s homes. There is naturally less supervision and opportunity for oversight in someone’s home. Since most care visits are undertaken by a single worker, there is also less chance that dedicated care workers can see abuse by their colleagues and either complain to responsible management or blow the whistle" (Koehler, 2014, p.19-20)

To ensure that those people becoming care workers are the right fit for the job, there is much work to be done to change perceptions of care work so that it becomes a viable career option for young people, professionalise the sector and introduce a system of licensing for all care workers. These efforts would equally serve to address the recruitment crisis itself.

Impacts on availability of care

To put it plainly:

"There is simply not enough money in the current system to provide care to everyone who needs it" (Koehler, 2014, p.14)

Local authorities are currently unable to pay home care providers decent hourly rates, meaning that increasing numbers of providers are deciding to only take on clients who fund their own care, leading to a crisis of care availability for those whose care is funded by the state:

“there are reports of some organisations withdrawing from contracts with local councils because they consider that the amount councils are prepared to pay for their services are not financially sustainable (Low Pay Commission, 2016)”

Lack of access to good quality social care is likely be most pronounced in the most deprived communities:

"poorer areas where Care Recipients cannot afford to pay will be left with services based upon low pay and inferior conditions for workers – reinforcing two tier services” (Kingsmill, 2014, p.34-35)

The crisis of unmet need is made worse by the fact local authorities only have enough resources to fund care for those with the greatest need:

"local authorities now restrict funding for social care to those with the most severe needs, meaning that individuals who might previously have been eligible for Government-funded care now either have to self-fund, rely on family, or go without. According to the Health Foundation, over 400,000 fewer older people accessed publicly-funded social care in England in 2013–14 than in 2009–10, a 26% fall despite the rise in the population of older people over the same period” (Health and Social Care Committee, 2020, p.10)

The extent of unmet is huge:

"Age UK estimated prior to the Covid-19 pandemic that 1.5 million people aged 65 and over in England has some form of unmet or under-met care need" (House of Commons Library, 2023).

If the above estimate is pre-pandemic, what must levels of unmet need be like now and how much worse will they get in coming years, as demand for services sky-rockets?

The process of accessing care also faces significant delays:

"The Association of Directors of Adult Social Services (ADASS) estimated, for example, that around 246,000 people were waiting for a care assessment in August 2022" (House of Commons Library, 2023)

Again, this will only get worse with rising demand, unless major reform takes place.

Such is the crisis of availability, you may be forced out of work to care for a loved one:

“Without a steady workforce able to provide Care to disabled and elderly people, increasing numbers of economically active people will be forced out of the job market – this is another false economy” (Kingsmill, 2014, p.22)

The bottom line

The following quote poignantly sums up why the current situation facing social care matters to everybody, not just care workers:

"Many of the impacts summarised above involve people and their families suffering quietly in their own homes – the sheer human misery caused by our ‘lost decade’ (the lack of reform by government since 2010) is simply not as visible as financial pressures on more prominent, popular and better understood services (hospitals or schools, for example).
When social care for older people is cut to the bone, lives are blighted, distress and pressure increase, and the resilience of individuals and their families is ground down. Yet this happens slowly – day by day, week by week and month by month. It is not sudden, dramatic or hi-tech in the way a crisis in an Accident and Emergency department may be, and tends to attract less media, political and popular attention" (Glasby et al., 2021, p.428)

Supporting quotes:

“Population ageing is the result of a long-term decline in fertility rates, which has coincided with people living longer” (GOV.UK, 2021)

“As the 1946 model of “diagnose, intervene, cure” gives way to the twenty-first century reality of “diagnose, intervene, live with a chronic condition”, society urgently needs a flexible, caring workforce with a common base of values and knowledge” (Cavendish, 2013, p.83)

“The extra years of life are not necessarily being spent in good health. As more people live to older ages, more of us are living with illness and disability, often with complex comorbidities and more challenges in managing everyday life” (GOV.UK, 2021)

“On the traditional male-breadwinner model, men and women were expected to perform different roles within society. Men would work outside the home to provide a sustainable income for the whole family, whilst women performed unpaid labour within the home, such as carrying out domestic duties and caring for children and the elderly. Care was organised and carried out within the parameters of a family home. With the decline of the male-breadwinner model and the rise of female employment, welfare states began making alternative care arrangements. However, the current Care Crisis suggests that the restructuring of Care Work has not adequately addressed the issues faced by the decline of the male-breadwinner family structure and the erosion of traditional gender roles” (Kingsmill, 2014, p.31)

“factors such as people having fewer children later, a higher proportion having none, and rising female employment all seem likely to reduce the number of people able to provide unpaid care” (GOV.UK, 2021)

"Making care work a career of esteem, where a living wage is paid, staff are trained and recognised as valued key workers who contribute a huge amount to society will inevitably come at a price, but the cost of doing nothing will be even greater" (Koehler, 2014, ii)

“Exploitative working conditions for Care Workers mean that there is a risk that they will only be able to deliver a rushed, poor quality service. The pressure that 15 minute care slots places on them means they are unable to give the human interaction that Care Recipients desperately need. Excessive time pressures and low levels of training lead to mistakes and, in a minority of regrettable cases, abuse” (Kingsmill, 2014, p.7)

"Continuity of care is a necessity for those with complex needs, but there can be little continuity in an industry where there is a just over 20% annual turnover rate in staff. This is over twice the average across all industries" (Koehler, 2014, p.14)

“the vulnerability of users and the high autonomy of staff who often work alone means that the maintenance of a quality and safe service is dependent on reliable and responsible staff” (Rubery et al., 2016, p.769)

“Although she is familiar with most of the people she sees and can provide continuity of care, some of her time is spent covering areas where the company she works for is short staffed. This means that she is unlikely to have seen these people before and may never see them again. She becomes part of the parade of unfamiliar workers who may come into someone’s bedroom and bathroom and take care of their intimate personal care needs. Some care recipients have reported having 50 different care workers in their home over a year" (Koehler, 2014, p.4)

“the Health and Care Professions Council regulates Social Workers but has no remit to oversee Care Workers, leaving the workforce completely unregulated” (Kingsmill, 2014, p.37)

“Local Authorities have reduced the amount of state funded care and increased the threshold for eligibility. 85% of adults over 65 now live in Local Authorities that arrange services for adults with substantial or critical needs only. 1% of adults now live in authorities which provide for critical needs only” (Kingsmill, 2014, p.35)

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