WF 27
Ymchwiliad i gynaliadwyedd y gweithlu iechyd a gofal cymdeithasol
Inquiry into the sustainability of the health and social care workforce
Ymateb gan: Cymdeithas Llywodraeth Leol Cymru a Cymdeithas Cyfarwyddwyr Gwasanaethau Cymdeithasol
Response from: Welsh Local Government Association and Association of Directors of Social Services
Inquiry into the sustainability of the health and social care workforce
Introduction
1. The Welsh Local Government Association (WLGA) represents the 22 local authorities in Wales, and the three national park authorities and three fire and rescue authorities are associate members.
2. It seeks to provide representation to local authorities within an emerging policy framework that satisfies the key priorities of our members and delivers a broad range of services that add value to Welsh Local Government and the communities they serve.
3. The Association of Directors of Social Services Cymru (ADSS Cymru) is the professional and strategic leadership organisation for social services in Wales and is composed of statutory Directors of Social Services, and the Heads of Service who support them in delivering social services responsibilitiesand accountabilities; a group of more than 80 social services leaders across the 22 local authorities in Wales.
4. The challenges facing social care have been well documented. As a result of demographic changes primary and community care services are facing increasing and more complex demands; more people are diagnosed with one or more preventable health condition; and frail, older people increasingly have more complex needs. This comes at a time when we will continue to experience severe austerity in funding for public services across the UK. Given the challenges being faced by public services it is appropriate that there is serious reflection on the impact these issues have on the health and social care workforce and how we support and develop the workforce to meet future health and care needs.
5. One of the conclusions drawn from NHS workforce review undertaken last year was that, “the widely held view across the service is that we currently lack an agreed strategic vision of what the NHS is intended to look like in Wales in ten years’ time…and that this inhibits the planning of new workforce models, new skill mixes and new roles. If this is true with regard to the health service it is even more the case with regard to an integrated health and social care service.“ We would endorse this statement. From the outset we need to be clear on what the vision for the workforce is – what are the expectations for the services that the workforce will be delivering. Without this direction it is hard to say how well-equipped the workforce is to meet future health and care needs.
6. We need to ensure that we have a workforce that will enable us to deliver high quality and where appropriate integrated care within the context of increasing demand. However, we also need to ensure that the system we have in place is sustainable. Local authorities and health boards are facing significant financial and demand pressures whichwill have long standing implications. In 2012 the Institute for Fiscal Studies report on local government expenditure in Wales showed that, until 2009-10, spend had been increasing in real terms by around 5% each year. This kept pace with inflation and service pressures. From 2009-10, spend has been reducing in real terms, but if expenditure had kept pace with general inflation, it would now be over £7bn. The resulting gap of £720m represents a conservative estimate of the cuts and efficiency savings achieved so far by local government. From April, councils in Wales face budget pressures of just over £200m due to inflation, demography and unavoidable financial pressures, e.g. the introduction of the single tier pension. It is likely that by 2019-20 there will be a cumulative budget shortfall of around £800m. The submission by WLGA and ADSS Cymru to Welsh Government on Social Services budget pressures last year indicated that social services departments in Wales faced unavoidable cost and demand pressures that will increase from £68m in 2016/17 to £234m by 2019/20. Clearly the ability to absorb any additional costs is virtually non-existent. At the same time we have seen significant investment into the NHS by the Welsh Government, however this has also not kept pace with demand.
7. In light of this, we believe that a more radical approach to integration is needed, with local government at its heart. This is critical if we are to shift focus and resources towards prevention and early intervention, rather than treatment or resolving crises. The Intermediate Care Fund has provided us with opportunities to develop new models of service delivery that have involved the integration of health, housing and social care, along with the essential contribution of third and private sector agencies. However, we need to learn from this, as well as from the approaches in other countries, in order to be able to accelerate this agenda in Wales, making better use of all available resources to both health and social services, to drive this forward towards more meaningful integration and improved outcomes.
Current Issues
8. In Wales, we do not currently have an online National Minimum Data Set (NMDS) which records accurately the state of our social care workforce. Lots of data is collected in a variety of different places but, unlike in England, we have no up to the minute coherent information system that can inform social care workforce planning about important issues such as regional and national vacancy rates, wage rates, levels of training, employment gaps, education levels, etc. Certain registers like the Care Council for Wales Social Worker register has accurate information about registered social workers but it is not a dynamic system and the annual social worker survey carried out with local authorities is only accurate at a point in time. Whilst these are essential in the absence of a NMDS, it is limited in the assistance it gives to decision makers.
9. Investment in an online NMDS system is required to enable Social Care Wales, CSSIW, employers, workforce planners and decision makers to work together on the basis of solid facts. This would help reduce duplication for employers completing a variety of information requests from different sources and provide confidence to make the right decisions about the future investment.
10. We have seen a number of recent studies focused on the social care workforce which have highlighted some of the significant challenges related to recruitment and retention particularly for domiciliary and residential care staff. One particular issue highlighted is in relation to pay and terms of conditions. The NHS workforce review, for example, heard evidence of what was seen as inferior terms and conditions of employment for social care staff carrying out direct care. Recent research undertaken by Manchester University, on behalf of Welsh Government, on the domiciliary care workforce identified that outside of local authorities, care workers uniformly expressed dissatisfaction with low pay and were also of the view that it did not reflect the levels of responsibility in the role.
11. The NHS introduced a living wage for staff in 2015 and whilst the announcement of a ‘National Living Wage’ by the UK Government may go some way to improving the offer to social care staff many social care providers are small, third and private sector agencies, who will find it extremely difficult to increase the wages of staff at a time when local authorities and health boards continue to look for efficiencies in response to their own financial constraints. Ultimately the risks will rest with local authorities if social care providers are unable to meet these requirements and assistance is not provided.
12. The phased introduction of a National Living Wage may help to improve recruitment and retention but this will be dependent upon funding to meet that funding gap. We also need to be mindful of the fact that the National Living Wage will apply to all sectors including retail and hospitality which the social care sector has reported losing staff to in recent times. Its implementation will significantly increases costs (by also causing a ripple effect in terms of pay differentials for supervisors and managers) without any improvement in recruitment and retention if there is no increase in relative pay for the role.
13. The recent Welsh Government consultation on the domiciliary care workforce was focussed on how best to recognise the important work done by domiciliary care workers, how to raise their profile and improve the quality of domiciliary care in Wales by having a positive impact on the recruitment and retention of domiciliary care workers. The proposals touch upon areas such as zero hours contracts, call clipping and payment for travel time. WLGA and ADSS Cymru submitted a joint response to this consultation which can be found here
14. The social care provider market has been fragile for some time and all the signs are that the difficulties will increase. For example, UKHCA have indicated that 71% of their members across England and Wales turned down local authority funded packages of care over the last 12 months. For some areas of Wales it can be very difficult to access home care to respond to complex cases or because of the rurality of the area, with the local authority provision having to fill the gap, often with difficulty.
15. In some areas of Wales we are also experiencing small family run providers who are deciding to retire from the sector. Younger family members are not choosing to take over the business due to the smaller profit margins, higher acuity of service users and requirements and future anticipated requirements of the inspectorate, all of which add further challenges to the sector.
16. Recent research on the domiciliary care workforce has highlighted some of the significant challenges related to recruitment and retention for this section of the workforce. The research by Manchester University concluded that a well-trained, well-paid and secure workforce with appropriate working patterns is required to recruit and retain care workers and to deliver high quality care. However the research findings suggest these are not conditions widely experienced outside of local authority employment in the domiciliary care workforce. With the majority of social care provision provided by the independent sector in Wales this has major implications for having a well paid, secure workforce.
17. Some of the conclusions drawn from this research support work undertaken by the Older People’s Commissioner for Wales looking into Care Homes. The Commissioner received evidence that low staffing levels are often the result of difficulties in the recruitment and retention of care staff. A number of reasons were stated for this, including poor levels of pay, low morale, long working hours that can include 12 hour shifts as part of a 60-70 hour week and the role of a care worker not being seen as a desirable and viable professional career option. This is a particular issue in rural areas and areas where the need for Welsh language speakers is high, as the number of potential care workers with the right skills can be especially limited. The review also concluded:
· Workforce planning is challenging due to a lack of demographic projections about future demand for, and acuity levels within, care homes. It is therefore not possible to quantify the right number of care staff needed in the future.
· The unregulated nature of the care home workforce in Wales, which means that data is not held on the number of care home staff in Wales, can also lead to difficulties around effective workforce planning.
· In relation to nursing staff, workforce planning is not effective as it is based only on the needs of Health Boards and does not consider the needs of residential care. This can cause particular issues around the recruitment of qualified and competent nurses to work in EMI (Elderly Mentally Infirm) settings as reported by several local authorities.
· There are issues around the recruitment of qualified and competent Care Home Managers and there is a lack of effective planning for current and future needs.
18. CSSIW and Care Council for Wales have also undertaken research into the recruitment and retention of adult care home managers in response to concerns over the high turnover and possible recruitment difficulties for registered managers of care homes for older adults in Wales. The study looked at what influences the recruitment and retention of managers of care homes for older adults, with and without nursing provision, across all sectors and identified some key influencing factors, including:
· The size of care homes and the complexity of residents’ needs
· The lack of a common set of data for the social care workforce
· Significant differences between the roles and responsibilities of adult care home managers, as well as their pay and other terms and conditions
· Negative publicity for care homes.
The overview report notes that the Independent providers spoken with acknowledged that the direction of travel in commissioning was a move from residential care to services that help people remain at home, but questioned the availability of the workforce to meet the future needs.
19. During the review, providers and managers were concerned that there were not enough nurses across the board and that recruitment efforts within the NHS are likely to exacerbate the problem for care homes with nursing. There were fears that the NHS will actively recruit the best nurses and that attempts to improve nurse to patient ratios within the NHS will leave the care sector even more vulnerable.
20. The pressures on the social care sector have been well documented and there is increasing evidence on the impact that this is having on providers in particular. It is important to recognise that many of these challenges will also impact on local authorities, particularly where there is in-house provision of services such as domiciliary care and care homes. Workforce stability is critical to the delivery of consistent, reliable services. Some local authorities have faced real challenges in both children’s and adult services particularly in light of growing demand for services and increasing caseloads. Across Wales we have seen a significant increase in numbers of looked after children and this has had a major impact on the caseloads within Children’s Services. Whilst many authorities have stable, resilient workforces many have also had to make progress in stabilising their front line workforce, particularly across Children’s Services. Despite reducing resources, local authorities have continued to invest in training and developing the workforce and with the implementation of the Social Services and Well-being (Wales) Act this will be key to ensure that we have an appropriately trained and competent workforce that is able to deliver the ambitious agenda set out in the Act.
Future Mix of Workforce and Services
21. We need to ensure that we take a whole sector approach to the health and social care workforce, which needs to apply to developing new roles and career progression. We need to be able to support a mobile workforce that can move between sectors, underpinned by training, qualification and progression opportunities. Career pathways are vital and we need to be able to support the workforce to be able to follow easy routes within and between health and social care, recognising the value of experience and not just simply qualifications. This includes the need to further develop joint training sessions across professional training programmes, supporting joint working and mutual understanding across different professional groups. The whole workforce includes the statutory, independent and third sector, but importantly needs to include unpaid carers and how they can be supported to access information, advice and training alongside the paid workforce. The SSIA have recently undertaken research looking to identify the improvement priorities for Social Care Wales and the findings re-inforce this view, with a need for a cross sector approach to training in order to build a mobile, flexible workforce with opportunities for career progression.
22. The new Social Services and Well-being (Wales) Act demands that we think differently about service provision otherwise if we keep doing the same thing we will continue to get the same results. We know that the current health and social care system is unsustainable. Apart from ensuring the paid workforce is up to speed and working together effectively, there has to be a massive transformation of attitudes and contributions made by communities and the support they are able to provide. We need a transformation of attitude in the health and social care sector to developing and supporting carers and volunteers otherwise our paid professional workforce will simply not cope. It is vital we tap into the enormous bank of knowledge, energy and experience of people in communities to support vulnerable people and we have to invest in this to make it happen. Preventative, early intervention and community based support have to be developed and we need to invest in this unpaid workforce to release that capacity.
23. Career development is a critical feature of sustainability. There is a need to ensure that people are encouraged to develop their skills, not simply to aid personal progression, but to enable a better skilled workforce. This includes a need to ensure that supervision and support is provided to the whole workforce. This can make a critical difference, allowing workers to reflect on their experiences and practice and being supported in their own personal development.
24. Changes in service provision have not shifted at the pace of changes in people's needs and wants, so we are still left with some service responses to policies and needs that were identified in late 1940s and 1950s, at the start of 'the welfare state'. In addition there has been insufficient development of services that will still be relevant in 20 years time, in particular recognising the way that digital technology is changing many people's lives. Telecare and telehealth are still relatively under-developed in Wales and this means that we are not exploiting the opportunities that they afford to people to have much greater control over their own health and well-being and this requires a workforce that is comfortable in recommending and demonstrating the benefits of new technology.
25. There have been moves in some parts of Wales to introduce generic health and social care workers, as a way of avoiding wasting time and energy on defining what is a health task and what is a social care task. However there remains a need to deal with the issue of medicine-administration, as this often turns out to be an issue on which a more generic role falls down. There are examples where staff have been suitably trained to administer medicine and these should serve as evidence that it is possible to find a way through some of the unhelpful professional boundaries.
26. Whilst advocating the development of generic health and social care workers, we are not suggesting the dilution of professional expertise. Actually the outcome should be a better trained workforce, both competent and confident to provide a greater sense of holistic care to people. There are now regular examples of care coordinators from a variety of professional backgrounds, e.g. Occupational Therapist, Social worker, nurse, physiotherapist. Each will still have some degree of specialist knowledge, but the difference should continue to be a care coordinator not looking to transfer responsibility to others, but bringing in others who can add value to their coordinating role.
27. Whilst there are examples of really good community-based services, they are still in the minority and still fewer that reflect shared responsibility between health and social care and NHS and local government. In Wales most health and social provision is sitting in private and third sector agencies and they have to be brought into the debate about planning for the future workforce.
28. There is a need for a stronger pool of consultant social workers and advanced practitioners amongst nurses and occupational therapists to carry out the developing number of leadership roles as well as offering coaching and mentoring, modelling best practice. The front-line workforce would, as a result, be better valued and better prepared, for the challenging nature of the tasks that they have to carry out. This does not replace the need for ensuring that they are properly rewarded for the demands of their job and that goes beyond the debate about a minimum or living wage.
29. In Wales, working with Social Services Improvement Agency (SSIA), Care Council for Wales and Universities, local authorities have invested in well established national social services management development programmes at first, middle and senior management levels as well as a sophisticated Continuing Professional and Education Programme (CPEL) for social work practitioners to ensure we continue to develop our social workers and their managers to meet the challenges of the future. This is essential in the sustainability for those elements of the workforce.
30. We need to give thought to how best to ensure access to services in the language of need and how to support front-line staff with language skills. This may include recognising and supporting those who have English as a second language, as well as securing adherence to the standards within “More than Just Words”.
31. In addition this review needs to consider how best to fully engage with housing associations (and local authority landlords who retain stock), with an overall workforce in Wales of 8,000, many of whom will have worked in public sector agencies, bringing shared values and yet key additional knowledge and skills into the mix of a whole system approach to the workforce. Housing associations make a vital contribution to the health of the population and many housing association staff are able to offer community work and community development skills, so essential to rebuilding mature and co-productive relationships with local people and their communities.
32. We have been clear in responses to the SSWB Act that the workforce will be fundamental to the successful implementation of the Act – requiring a workforce that is multi-agency and multi-disciplinary. The Act requires a very different way of working, particularly around the new approaches to assessment and eligibility, that will not be simple to apply and will challenge some of the existing practice and training. The right kind of staff training and development will be essential, in order to support staff to be able to meet the expectations set out in the Act, with realistic timescales for the changes to become embedded into people’s everyday practice. Some of this work has already started, for example having an increasing focus on outcomes, however the size of the changes required and the new expectations cannot be under-estimated.