A major societal concern of our time is making health and social care systems fit to meet the needs of people with long term conditions, frailty, and disability. In the UK, during 2022, it was estimated that nearly 27 000 excess deaths occurred because of systemic pressures on NHS emergency departments.1 But emergency departments were the canary in the coalmine, indicating much wider system failure across primary and secondary health and social care. In December 2022 around 10% of acute hospital beds were occupied by patients who were designated as ready to leave hospital, amounting to over 13 000 people a day.2
Most of the people stuck in the system had care needs characterised by the complexity that accompanies frailty, disability, and multimorbidity. These people were not universally old, but the pressures of our ageing population, including a predicted doubling of those with four or more multi-morbid conditions by 2035,3 will push healthcare systems to collapse unless action is taken now.
A major contributor to whole system decompensation in the winter of 2022 was the inability of hospitals to discharge into social care. This is not in itself a new problem, but it is now being seen on a different scale.2 We don’t state this to blame colleagues in the social care sector but rather to highlight the extent to which health and social care systems are co-dependent. Furthermore, and particularly in care of older people, the distinction between health and social care is arbitrary and blurred. In the UK, the two systems are funded separately and by distinct means (and differently in each UK jurisdiction) for historical and political reasons not replicated in most other countries. The responsibilities of health and social care teams are delineated largely by custom, practice, and professional boundaries. These are at best opaque and at worst bewildering for service users and their families. Rehabilitation and reablement, for example, overlap in concept and execution and are perceived similarly by participants.4 An older patient with heart failure will have the treatment of their breathlessness delivered and funded by healthcare but the consequences of their breathlessness—such as needing help with daily tasks—is classified as social care and requires a separate assessment and funding mechanism.5 Effective healthcare delivery in care homes, meanwhile, requires complex and often lengthy negotiation between health and social care teams to work out who needs to do what to deliver the common aim of person centred care.6
A major contributor to shortages in social care places, and thus system block, during winter 2022-23 was the collapse of the social care workforce. Some 165 000 vacancies were reported across the adult social care sector in England by Skills for Care in 2022—up 52% from the preceding year and reaching an all time high.7 Both health and social care are, at their heart, still people projects—staff shortages cripple the ability to deliver them effectively. People living with disability and frailty need human hands to provide physical support, and human presence to provide psychological connection.
Barriers to recruitment and retention in social care are manifold. Social care staff are invariably poorly paid—for care assistants at or below the minimum wage.7 Benefits and pension plans are limited, if available at all. Opportunities for career progression and continuing professional development are limited. Staff in the NHS—themselves currently engaged in industrial action because of deteriorating working conditions—receive preferential treatment in nearly all these domains, meaning there is a net flow of staff from social care into healthcare.8 All these matters have been compounded first by the covid-19 pandemic, which placed substantial psychological stress on social care staff, then by the cost of living crisis, which has made the financial inequities even more acute.
Most social care is of high quality. In the 2021-22 Care Quality Commission State of Care report, 83% of adult social care services were rated as good or outstanding. But the same report described a small increase in the number of care homes and homecare services requiring improvement and found that 2.2 million hours of care had gone undelivered because of staffing shortages.9
Investment in the workforce must therefore be a key priority for any government seeking to improve the quality of care and minimise ongoing acute sector delays. The care certificate, introduced in 2015 by Skills for Care, outlines 15 standards and was designed to develop and recognise core skills in the social care workforce.10 But much needed efforts to drive up pay and improve conditions in the sector, at least to the level of equity with NHS colleagues undertaking equivalent work, are likely to be complicated by regulatory concerns about training and certification in the sector.
Against this background, the announcement from the UK government that the budget for training the social care workforce is to be halved is startling.11 The reduction from £500m of pledged funding to only £250m devalues the importance of the people already working in social care and can only deter others from following this career.12
This is a priority for the whole health and social care sector—which cannot function adequately until it is better equipped to care for people with multiple long term conditions, disability, and frailty. A functioning social care sector is key to this, and a valued workforce is the bedrock of social care.
Care staff must be valued—not just by better remuneration and career opportunities but also in increased societal recognition of the vital role that they play. Care has implicit worth—we will continue to experience the problems we currently see if we fail to grasp that fact.
Our government needs to invest adequately and develop the care workforce. The rest of us working in care—whether we identify as health or social care professionals—must campaign ardently until they do.
Footnotes
-
Conflict of interest: none declared.
-
Commissioned, not externally peer reviewed.