Key points
- There is unsustainable pressure on health and care services, driven strongly but not exclusively by the severe capacity challenges affecting social care. Like the NHS, the sector faces steep vacancies and is struggling to recruit and retain staff desperately needed to keep people well at home and support them to leave hospital safely.
- 99 per cent of healthcare leaders responding to our latest survey agreed that there is a social care workforce crisis in their local area. Almost all agreed it is worse than a year ago and expect it to deteriorate into this winter.
- These pressures are impacting the whole health and care system’s ability to deliver care across community and acute settings. For instance, 85 per cent of those surveyed agreed that the absence of a social care pathway is the primary cause of delayed discharge of medically fit patients.
- Almost three-quarters (73 per cent) said a lack of adequate social care capacity is having a significant or very significant impact on their ability to tackle the elective care backlog. Over 80 per cent said it is driving urgent care demand.
- Although health and care are inextricably linked and interdependent, social care is not just about helping to alleviate pressure on the NHS. The care delivered by social care services is critical to the wellbeing of the nation. However, patients will continue to face long delays for treatment unless the government invests in social care to boost capacity. Healthcare leaders stand in support of their colleagues in social care and are calling for urgent government action to tackle this capacity crunch.
- Healthcare leaders are calling on the government to back social care with a fully funded pay rise to boost recruitment and retention, alongside providing greater overall investment and improved career progression opportunities. This will help to stop the exodus of staff leaving for better paid and less stressful roles in other industries like hospitality. There is no time to waste, and action must be immediate to not only ensure people do not have their health outcomes further threatened, but to also ensure capacity gaps are not worsened.
- Healthcare leaders are clear that the NHS and social care will sink or swim together. New integrated care systems (ICSs) encompass both health and care and are acutely aware that both need sufficient resourcing if ICSs are to succeed in their essential task of improving health and sustainability.
- So, what now? As we wait to find out who the next Prime Minister will be, healthcare leaders are asking for a ‘realism reset’ on the state of health and care. This needs to properly acknowledge where the ten years of austerity in the 2010s have left health and care services. It also needs to include an acknowledgement that social care is not ‘fixed’ as the government continues to insist. The priority must be to close the gulf between demand and capacity – particularly in the face of continued COVID-19 spikes, a cost-of-living crisis and what we expect to be another gruelling winter.
Introduction
NHS frontline services continue to come under extreme pressure, with the latest performance statistics once again revealing the gap between rapidly rising demand for care and the NHS’s capacity to respond. The service saw record A&E attendance and ambulance call outs in June, as well as continued pressure on primary care, with a lack of capacity in the rest of the patient pathway adding to the challenge. This looks to continue into the summer – traditionally a period of respite for the system but not in recent years.
Social care services play a crucial role in care pathways – keeping people well for longer outside of hospital and enabling faster, safer discharges home. As such, the sector plays a critical part in protecting NHS capacity and its ability to deliver high-quality, safe care. However social care itself is showing signs of crisis in the face of severe pressure. The sector finds itself in a continuous cycle of underinvestment, struggling to recruit and retain staff and thus seeing fewer people, leaving them less independent, more vulnerable and more likely to rely on healthcare services.
To understand how this crisis of care is playing out on the NHS frontline, we asked our members – the organisations that plan, provide and commission NHS services – to describe the impact that staff shortages and a lack of capacity in social care is having on NHS services, as well as what effective solutions may look like.
In total, 243 leaders from across our membership responded to the survey, which closed 19 July 2022. Responses came from all parts of the NHS in England, with 55 per cent representing NHS trusts (acute, community, mental health and ambulance), 18 per cent from primary care and 18 per cent from integrated care systems (the remaining 9 per cent coming from ‘other’ organisations including community interest companies and voluntary sector providers). Responses were relatively evenly spread across the seven NHS regions in England.
The state of the health and care service
A social care workforce crisis
Almost all (99 per cent) of healthcare leaders agreed that there is currently a social care workforce crisis in their area. Almost all further agreed that the crisis is worse than it was 12 months ago (94 per cent) and expected it to deteriorate even more as we move towards winter (92 per cent).
This is not surprising. The sector finds itself in a cycle of underinvestment and has experienced major challenges related to the recruitment and retention of staff for many years. These have been acutely felt in the last few years in the wake of events such as COVID-19 and Brexit, with vacancy rates in the sector reported to have risen sharply in the last year. These challenges put pressures on the sector, its workers and users, with care providers increasingly having to rely on expensive agency staff and feeling forced to turn down new clients.
However, the issue is becoming increasingly urgent, compounded by spiralling inflation and intense labour market pressures. The Association of Directors of Adults Social Services’ (ADASS) July 2022 assessment of adult social care reveals significantly more people seeking support and rising cases of breakdown of unpaid carer arrangements. Simultaneously, almost 7 in 10 directors say that care providers in their area have closed or handed back contracts to local councils. Many more cannot deliver the increased care and support needed due to staffing shortfalls.
ADASS’ findings in the social care sector illustrate the extent of the interdependency between health and care, with squeezed capacity in primary and community care an important factor impacting demand for care services. Most directors reported increased referrals of people discharged from hospital and over half are recording more referrals and requests for support from the community. They are also underlined by the response to our survey, with 98 per cent of healthcare leaders agreeing that the knock-on impact of the workforce crisis in the social care sector is putting the care and safety of patients in the NHS at risk.
Interlink between capacity constraints and hospital discharges
With a range of different services involved, the reasons for delays in the hospital discharge process are multiple and complex, including internal hospital procedures. However, given the number of people who will require ongoing support following their medically fit diagnosis, without a good supply of well-staffed social care (care homes, home care, supported living and other services), people can be less easily discharged from hospital in a timely way. 85 per cent of the healthcare leaders surveyed agreed with this, saying that the absence of a social care pathway is the primary cause of delayed discharge of medically fit patients.
Their concerns are reflected in the current challenges in discharging patients. The proportion of patients remaining in beds who no longer met the criteria to reside has remained high throughout winter into the summer months. In the week to 26 June 2022, over half of medically fit patients remained in hospital unnecessarily. Based on delayed discharge data available before the pandemic, the amount where a social care service took part or all responsibility for the delay ranged from 31 to 45 per cent.
Social care is also the foundation of high-quality community mental health services and lack of capacity in the sector impacts on patient flow across the system. Indeed, as social care pressures have increased, so have those in mental health – in the year to April 2022 there was a 122 per cent increase in the number of days people were delayed leaving mental health inpatient beds attributed to social care. One of the key drivers is a lack of appropriate housing, which relies on social care funding and packages being in place after discharge.
These delays all lead to longer stays in hospital, which can damage people’s confidence to live independently as well as their health – particularly for older people where extended stays can also be associated with loss of muscle tone, falls and rapid deterioration. This means not only poorer outcomes and greater reliance on services for those patients involved, but fewer beds available in that hospital for new admissions – emergency or elective.
“Even with the significant uptick in COVID-19 admissions we have had in recent weeks, the number of patients delayed for a social care package is broadly equivalent to the number of patients with COVID-19. It is a very significant constraint AND it is dreadful for the patients experiencing the delays who come to real harm and decompensate - the system is doing real damage to people. 25% of falls in my organisation are in patients who are medically fit for discharge. Moreover, the significant majority are elderly and probably in the last 1,000 days of life and we are robbing them of precious time by holding them in hospital. It is shameful.” Acute CEO, North West
Impact on preventative care and keeping people well at home
Beyond delayed discharge, the most significant impact of the lack of adequate capacity in social care cited by members was around emergency department (ED) pressures and ambulance waiting times. Over 80 per cent of healthcare leaders said that social care capacity had either a very significant or significant impact in driving urgent care demand.
We can see this pressure playing out in recent performance statistics, including the service recording the second and third highest total A&E attendances on record in May and June this year. As well as exacerbating emergency pressures, the impact on primary care services of the lack of adequate capacity in social care was highlighted, with 57 per cent of respondents rating it as significant or very significant.
This is not a one-way relationship – the lack of capacity in primary care and community is also an important factor and leading to more pressure in care services. However, without allocated social workers in place, we see self-neglect cases increasing and GPs themselves are supporting patients' personal care during home visits. Ambulance crews and families are also contacting GPs due to poor housing situations and being unable to contact social care. This has increased time spent on paperwork and liaising with families, reducing appointment capacity in an already stretched sector that has seen a 12 per cent increase in the number of appointments compared to the same month in 2019 to 28.3 million, including COVID-19 vaccinations, pointing to rising needs in the community overall.
“Last week I had to clean urine off the floor to prevent a patient slipping over as they had no family or package of care.” – GP
As highlighted by ADASS’ recent report, adults and children's social care services have seen a significant increase in demand for their services in areas where there are risk factors for mental health problems like domestic violence, child protection, child abuse or children coming into care. Given the challenges in the sector, it is not surprising this is having a knock-on effect elsewhere.
In fact, 63 per cent of healthcare leaders responding to our survey agreed a lack of social care capacity is also resulting in increased demand for mental health services. This view is supported by the recently documented increase in referrals to children and young people’s mental health services of 77 per cent and the fact that overall mental health bed occupancy rates have remained above safe levels since spring 2021. Recent data also suggests that waits of over 12 hours in A&E for mental health reasons have increased by two and half times since before the pandemic.
Impact on the elective and diagnostic backlog
The NHS has worked hard to ramp up elective activity and is providing more people access to the care they are waiting for. This can be seen in the highest ever number of diagnostic tests and checks being carried out for the month of May at over 2 million, and activity at over 99 per cent of pre-pandemic levels, despite continued prevalence of COVID-19 cases. However, total elective waiting list is still rising – now at 6.6 million – and referrals are increasing. This is in addition to the backlog in mental health care, which currently sees 1.6 million people waiting for services.
Clearly there is further to go. Bringing the waiting list down will require the system to be working at its most effective, which relies on few disruptions and free patient flow in, through and out of the hospital and, in turn, adequate capacity in social care. These conditions currently do not exist. Indeed, 73 per cent of respondents to the survey agreed the impact of a lack of adequate social care capacity on their ability to tackle the elective and diagnostic backlog is significant or very significant.
The extent of the challenges with patient flow are demonstrated in bed occupancy rates that remain consistently close to 90 per cent, a trend that is worsening. Recent Health Foundation analysis has found that even if the NHS continues to reduce the length of time people stay in hospital, 20 to 35 per cent more beds could be needed in 2030/31 to maintain pre-pandemic standards of care. The issues are also reflected in emergency performance, with recent A&E four-hour performance data showing that the last four months have been the worst ever recorded, with less than 60 per cent of people being seen in that time – further emphasising the lack of available space and capacity to see and treat people and to move people into the hospital.
Greater investment required to support social care
We asked healthcare leaders to consider a range of potential options for supporting the challenges being felt in the social care sector and indicate the extent to which they might be effective. The action that the most felt would be ‘very’ or ‘quite’ effective was to increase pay in the sector, with the aim to improve social care recruitment and retention (64 per cent and 32 per cent respectively).
This echoes our recent call for the government to implement a national care worker minimum wage. We warned that without an increase above the hourly wage seen across many other industries, including that paid to staff working in supermarkets and across retail, the social care sector in England would continue to haemorrhage staff.
At a time when many people are facing a spiralling cost-of-living crisis, and with numerous industries reporting problems filling vacancies, we know healthcare leaders fear that their colleagues in social care have the impossible task of trying to shore up huge staff vacancies with their hands tied behind their backs. The additional risk remains that the more competitive levels of pay offered by the NHS for similar roles could see an ever-widening gulf in remuneration between health and social care.
“Pay is the number one reason more than ever. People can't afford to live right now and you want them to come to or continue working in some of the hardest jobs mentally and physically for literally less than peanuts (if they could even afford peanuts on their pay).” - PCN Manager, South West
Crucially any wage increase must be fully funded by the government, distributed through local authorities, to ensure funding reaches the front line, does not impact self-funders’ cost of care, and alleviates these severe staffing challenges.
In addition to increases in pay, there was strong support among healthcare leaders for an increase in investment to expand overall social care capacity (94 per cent) and for improved career progression opportunities to improve recruitment and retention (93 per cent).
On overall investment, the Health Foundation projects the government would need to spend between an extra £2.5 billion (just to meet future demand) and £9.3 billion (to also improve access to care and pay more for care) by 2024/25. However, the recent funding announcement covers only some of this. Only £5.4 billion of the £36 billion raised through the national insurance rise over three years will go to social care. And the majority of this will fund the cap on costs – protecting individual’s savings rather than to improving services themselves.
“Listen to social care, value and respect its complexity and uniqueness in helping people to live the lives they want to live with care, support and safeguards if needed. It's not ancillary healthcare and it's not something to be prescribed. People have fundamental human rights and rights to representation if they lack the capacity to make decisions themselves. Social workers will work with people to weigh up the risks and benefits of options and as a result LESS care may be needed. Respect that the interface with the NHS is only one aspect of integration for social care - of equal importance is the interface with communities, housing, leisure, employment, the police and criminal justice system etc. Focus on quality and outcomes, not just process and capacity. There is evidence (University of York) that investment in social care has more impact than investment in the NHS.”
On career progression, while the government has previously acknowledged that a workforce strategy for social care is required and has acted to place care workers on the shortage occupation list to support overseas recruitment, this has not been enough to stop social care staff leaving the service in their droves. More is required to make a career in the care sector something to aspire to and one that offers opportunities for development and ensures people who work in the sector know that they are valued as professionals.
“The terms and conditions for social care staff should be commensurate with the important role they play as key workers in our society. These should be integrated with healthcare to provide aspiration, career opportunities and personal development.” – Acute Chair, Midlands
Although not rated as the most impactful solution to the challenges facing the sector, over 90 per cent of leaders agreed that better integration between health and care services was important. This aligns with a wider agenda put onto legislative footing by the Health and Care Act 2022 this year and confirms that new ways of working are also important alongside investment in staffing numbers. While staff remain employed by different bodies, there are opportunities to support unified approaches on areas such as workforce planning, access to training, and health and wellbeing. Our members view these approaches as a clear priority and there are examples of highly effective integrated ways of working being adopted across the country.
Viewpoint
There is a strong relationship between the NHS and social care. The care sector is not simply an adjunct to the NHS. But, where the NHS and social care work well together, there is potential to keep people well and reduce demand on other health and care services.
The government’s top priority should be to bolster social care
The fact that high levels of unmet need and systemic pressure, evidenced through significant delays in people’s care, have become the norm, is a major concern. The pandemic created a shock to our lean health service, the effective running of which relies on few disruptions and free patient flow. We can no longer ignore the impact of prolonged periods of underfunding in the past decade, lack of an adequate workforce plan and a failure to undertake meaningful social care reform.
The government’s top priority should be to bolster social care. Given the urgency of the situation, we should start where the crisis is most severe and where we are able to make a difference – action to stem social care workforce shortages. As our survey has found, healthcare leaders’ are calling for the government to:
Increase pay in the social care sector, starting by immediately implementing a national care worker minimum wage
Publish a long-term, properly funded plan to develop the care workforce and offer career progression opportunities
Commit to increasing overall investment to increase access to care to those who need it, meet future demand and pay more for care
These measures will help to stem the flow of workers from the sector and support recruitment efforts, and thus improve access to publicly funded social care. This will help prevent more frail older people from deteriorating and maintain independence, as well as supporting more disabled people to improve their wellbeing and live the lives they want to lead.
This will have a positive and amplified impact across the health and care system. For the health service, this action will begin to relieve some of the patient flow pressures, starting with reducing the delays to discharge for those who are medically fit to leave hospital, reduce emergency demand and reduce negative impacts on health outcomes.
Failure to act will miss the opportunity to put the health and care system on an even keel
We have consistently made the case for reform and taken a leading role via the Health for Care coalition to campaign for greater funding and support for our colleagues in social care. And we will continue to do so because the sector needs fully funded reform to deliver value well beyond that we can see from where we sit in the health service.
We hope to see the health and wellbeing of those who most need support at the heart of the campaigns of the future leaders of this government. Bolstering social care capacity should be a top three priority when they are elected, especially ahead of what we expect to be another gruelling winter. Failure to act will miss the opportunity to put the health and care system on an even keel and the road to genuine recovery.
