Balancing acts: Navigating the complex risks in adult social care provision

On 29 July 2024 the Chancellor, Rachel Reeves, announced that there was a £22 billion hole in the government finances, such that difficult decisions had to be made. One of those difficult decisions was to defer, yet again, plans to reform the adult social care system. 

So, what does this mean for the future of adult care, at a time when data tells us that the general population is living longer and with more complex health needs? And what are the risks flowing from a system where society expects access to social care as a fundamental right, but the point of access is means tested? How is it that a 65+ year old who fractures their hip and receives free health care at the point of access, but whom on discharge may be means tested to receive ongoing care and support in their home? The chasm between health and social care is currently stark, but what are the risks?

Over a series of articles, we will explore the risks of the ongoing financial crisis in adult social care, engaging with experts and stakeholders to consider some ways to mitigate the risks, culminating in a series of workshops where we will bring these issues to life. 

Workforce

The care system has the highest number of vacancies at a time of increasing need. One in 10 social workers and one in 11 care worker roles are unfilled,with Skills for Care estimating that by 2035, there will be a need for 650,000 to 950,000 new adult social care jobs to meet anticipated requirements. Whilst the 2023 report saw improvements in workforce capacity, there were 152,000 vacancies per day with 390,000 carers leaving jobs; many exiting the sector altogether. (1) A 2021 study of providers found that the most reported ongoing challenges were in recruiting and retaining staff, and issues accessing bank workers. With a push for supporting individuals to have choice over care and independence in their own homes, domiciliary providers reported that personal assistant or home care work was a challenge. (2) Ordinarily, when unemployment figures are low, there is a correlating decrease in open vacancies in the care sector. Recent data is showing that despite at times worsening unemployment figures, there has not been an uptick in the numbers of people entering the adult social care profession. The impact of Brexit and COVID-19 on the availability of foreign workers cannot be overlooked, but long-term systemic issues are said to be at play: uncompetitive wages, low societal value placed on the role, and limited career development. 

What are the risks? 

1. Quality of care reduced. Workforce shortages are reported to directly impact the quality of care a person receives. (3) A 2021 Unison survey of 1,600 care staff revealed that service users were receiving sub-optimal care: left in soiled bedding, reduced personal care, and lack of dignity at the end of life. (4). 
2. Employment and HR issues. Burnout, stress, low morale impacting on service provision and workforce planning. Absences and low morale, leading to increased pressures with staff unwilling to work extra hours or take on additional responsibilities to cover absent team members. (3) underpinned by an inability to train. 
3. Increased claims, inquests and reputational damage. 

So, what can you as a provider, private or public, do to minimise those risks at a time of continued financial crisis? Primarily an understanding of the risks is needed in order to implement strategies to minimise those risks, i.e., a detailed and comprehensive assessment of your risks is needed. From there, strategies to tackle defined risks can be designed and implemented: 

1. Document retention and accurate record completion is the foundation of driving a disciplined approach to culture and building out good behaviours. 
2. Training of staff at all levels, beyond just how to carry out their jobs safely, but to better understand their roles in the context of the special needs of adult care service users. Develop a ‘this is a valued profession’ mindset. 
3. See incident reports and public service failure reports as an opportunity for recovery and improvement, where leaders lean into a ‘no blame culture’ and view incidents/failures as an opportunity for learning and development.
4. Develop a continuous improvement mindset. 

Whilst the strategies to mitigate are multifaceted and will need policy reform underpinned by increased funding, the upcoming series will play a pivotal role in bringing these issues to the forefront, which we hope will facilitate stakeholder discussions in order to explore viable and effective strategies, which minimise the risks.

1. The state of the adult social care sector and workforce in England, Skills for Care 2023.
2. DoHSC Adult social care workforce survey December 2021. 
3. The CQC’s 2023 report into the quality of health and adult social care in England.
4. Unison “Staffing levels in care ‘dangerously low’ with dying residents denied dignified end”.