The consistent message in recent submissions to the Senedd enquiry on the Health and Social Care workforce strategy was that the social care workforce is in ‘crisis’. Services are struggling to find or retain staff. And, of course, the provision of high quality care is dependent upon the social care professionals who have the skills, capacity and motivation to care for those in need. Staff shortages are now at the forefront of the declining quality of care, having an immediate and at times devastating impact on staff and patients.
This ‘crisis’ isn’t just a problem for social care. Health and social care are entirely interdependent – an improved social care system reduces the burden on healthcare and vice versa. And yet health and social care staff work in two separate systems, with different legislation, funding mechanisms and regulation. While there are workforce issues in both, the consequences are being felt more acutely in social care.
Neither is this just a problem for Wales; many of the causes and consequences are being felt across the UK. Here we explore how these are playing out for social care workforce in Wales, and efforts to address the workforce crisis in Wales.
What is causing the workforce crisis in Wales?
All workforces are at the whim of social, economic and political forces. For social care these are converging to create a perfect storm, affecting both demand and supply of staff.
There are not enough social care workers and too many people needing care. According to the latest census the number of people living in Wales has risen by nearly 20 per cent since the 1950s, and one in five of our 3.1 million population are now aged 65 or over. In some regions in Wales older people account for 27.8 per cent of the total population. With an ageing population comes increasingly complex health needs and this demand will likely be intensified by the cost-of-living crisis and its impact on health and wellbeing.
Supply of staff has been affected by reduced immigration since Brexit, and an increasing number of social care staff seeking employment in healthcare, retail and hospitality. Vacancies for social care staff across the UK increased by 124 per cent between January 2019 and February 2022. In September 2021 there were reports of 700 unfilled jobs in the care sector in Wales.
High vacancy rates are linked to poor pay, regulation and working conditions. Social care workers used to be paid a premium over other occupations such as retail and hospitality, with hourly pay being over 5 per cent more in 2011. This premium fell to just 1 per cent in 2021. Disparities between health and social care have also increased, with terms, conditions and progression being better regulated and standardised in healthcare. Whilst there is a national system of regulation and inspection in Wales, the delivery of the social care is highly fragmented. There are multiple employers, no single body for determining pay, and the price paid for care by Local Authorities is determined by individual negotiations between commissioners and independent providers.
Poor working conditions had catastrophic consequences for social care staff during the COVID-19 pandemic. Rates of COVID deaths for residential and domiciliary care workers were double that for health care workers. Care workers in Wales have reported on the factors that put them at risk during the pandemic: lack of and poor quality PPE; poor statutory sickness pay; casual or zero-hours contracts; and the requirement to give up additional employment, amongst others. Those feeling undervalued, underpaid and poorly supported through the pandemic sought alternative employment.
Social care is undervalued, in part because it is chronically underfunded. Social care funding fell almost 2 per cent a year from 2010 to 2015 and when adjusted for rising numbers of people needing care, the fall in funding continues to be substantial. The UK Government’s announcement in September 2021 of increased investment in social care increases funding available to the Welsh Government, and while it is not clear how this will be used, it is clear that it won’t be sufficient. The cost of living crisis is already accelerating, with increased petrol prices adversely affecting social care staff, and rises in heating and food costs affecting the provision of care. To increase quality of care, a high-skilled workforce is needed that is properly renumerated; long-term underinvestment in the system suggests this ambition might be hard to realise.
Navigating this complex array of social, economic and political factors requires a joined-up and comprehensive approach, before crisis becomes collapse.
What is being done to address the crisis?
Key pieces of devolved legislation and policy set the framework for addressing social care workforce issues, particularly the Social Services and Wellbeing (Wales) Act 2014, Regulation and Inspection of Social Care (Wales) Act 2016, A Healthier Wales: Our Plan for Health and Social Care (2018) and the Health and Social Care Workforce strategy (2020). There are common threads across these, pushing for ‘seamless’ provision across health and social care, and increasing efforts to address demand through preventative population health measures. The value of the workforce is a central feature, with one of the four pillars of success being to develop a motivated and sustainable health and social care workforce.
Despite this supportive policy framework, Wales is still facing an acute workforce crisis. In a recent consultation, many commended the ‘admirable’ workforce strategy but highlighted the challenges of addressing the crisis whilst attending to the provision of care with a skeleton workforce. The pledge to implement the real living wage for social care staff has been welcomed but is seen as insufficient, with many highlighting that fair pay should be a proper, fully negotiated pay strategy that recognises different levels of skills and responsibilities and renumerates accordingly.
Further work is being done to try to address these challenges. A Social Care Work Forum has been established to bring together government, employers and unions to review pay, terms and conditions for care workers. An expert group has been established to examine the creation of National Care Service, with recommendations due imminently. The White Paper on ‘rebalancing care and support’ includes a commitment to a national framework for commissioning that aims to address the fragmentation of social care delivery, and improve terms and conditions across the sector in Wales.
Will it be enough?
Efforts to address the social care workforce crisis in Wales are significant. Policies outline the need to fix the fragmentation of social care services, and improve the integration of health and social care services, for patients and for the workforces that deliver care. These efforts are operating in an ever more challenging social and economic context. We are yet to see whether the policy aspirations of an integrated system that provides training, funding and support to staff can be realised quickly enough to address this crisis.