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Systemic safety inequities for people with learning disabilities

A study examining safety inequities experienced by people with learning disabilities in English health and social care, drawing on lived experiences from focus groups and patient feedback narratives.

Key statistics 

  • people with learning disabilities in the UK experience substantially reduced life expectancy, with earlier mortality linked to avoidable or preventable conditions 
  • prior evidence cited in the study shows deaths occurring on average 22 years earlier for men and 27 years earlier for women compared with the general population 

Key messages 

  • people with learning disabilities experience systemic safety inequities when accessing health and social care services 
  • health and social care systems are often rigid and poorly adapted to the complex needs and communication requirements of people with learning disabilities 
  • failures in communication, information accessibility and reasonable adjustments increase risks to patient safety 
  • discontinuities in care, staff shortages and poor interoperability between services contribute to avoidable safety risks 
  • family members, carers and advocates frequently act as informal safety buffers within the system 
  • reliance on social support networks creates additional inequities for individuals who lack strong advocacy or family support 
  • improving safety requires system-level change, including better service design, staffing, training and coordination across health and social care 

Policy implications 

  • improve implementation of reasonable adjustments for people with learning disabilities across health and social care services 
  • increase specialist learning disability roles such as liaison nurses across care settings 
  • strengthen continuity of care and coordination between services, including better information sharing systems 
  • invest in accessible communication methods such as easy-read materials and personalised care plans 
  • develop stronger advocacy provision to support people with learning disabilities when interacting with services 
  • address workforce shortages and training gaps affecting safe care delivery 

Gaps 

  • demographic characteristics of participants were not extensively collected, limiting analysis of how inequities vary by factors such as ethnicity or socioeconomic status 
  • qualitative findings provide strong insight into experiences but cannot quantify the prevalence of specific safety issues 
  • more research is needed on interventions that effectively reduce systemic safety inequities 

Commentary 
This study explores systemic safety inequities experienced by people with learning disabilities when interacting with health and social care services. Rather than focusing solely on mortality data or adverse events, the research examines lived experiences of care to identify structural factors that contribute to unsafe or inequitable care. 

The analysis identified three overarching themes: health and care system rigidity, systemic gaps and traps within services, and the reliance on ‘dependency work’ undertaken by families, carers and advocates. These findings suggest that inequities are often produced by structural features of health and social care systems rather than by individual-level factors. 

System rigidity was a key issue. Health and social care services often required people with learning disabilities to adapt to standardised systems rather than adapting care to individual needs. Participants reported difficulties with communication, inaccessible information, insufficient time during appointments and environments that could be overwhelming or distressing. These barriers increased risks to patient safety and reduced the ability of individuals to participate fully in their care. 

The study also highlighted systemic gaps within services. Participants described inconsistencies in support provision, limited staffing capacity, poor coordination between services and failures in information sharing across organisations. These issues often led to fragmented care and repeated retelling of medical histories, which created additional burdens for individuals and families. 

A particularly important finding concerns the role of family members, carers and advocates in compensating for systemic weaknesses. Family members, carers and advocates frequently acted as informal safeguards by interpreting information, advocating for reasonable adjustments and ensuring that care needs were understood. While this support was valued, the study emphasises that reliance on social capital can create additional inequities for individuals without strong support networks. 

In terms of care equity, the study shows how structural barriers within service design, staffing and coordination contribute to poorer safety outcomes for people with learning disabilities. Addressing these inequities therefore requires system-level change rather than relying solely on individual staff training or local adjustments. 

Overall, the findings suggest that improving safety for people with learning disabilities requires more flexible service design, better communication practices, stronger advocacy support and improved integration across health and social care services. These changes would help reduce systemic safety inequities and improve care experiences for this population.

Newly qualified social workers and anti-racist practice in England

A qualitative study examining how newly qualified social workers in England experience and respond to racism in practice, and how social work education prepares them to challenge racism in health and social care contexts.

Key statistics 

  • the study included 67 newly qualified social workers within two years of completing their social work degree in England 
  • participants were drawn from multiple routes into social work: bachelor’s degree (31), postgraduate programmes (22), and fast-track routes such as Frontline, Think Ahead and Step-Up 
  • the majority were employed in local authorities (58 participants), with others working in the NHS or other settings 
  • the sample included 28 white participants and 24 Black participants, with others identifying as mixed race, Asian or other ethnic backgrounds 

Key messages 

  • newly qualified social workers report limited preparation during training for dealing with racism in practice 
  • racism occurs in multiple parts of the system, including interactions with colleagues, people who draw on care and support and partner agencies 
  • social workers from minoritised ethnic groups experience racism from people who draw on care and support and colleagues but often feel unsupported by management 
  • fear of being labelled “angry”, “problematic”, or “unprofessional” discourages practitioners from raising concerns about racism 
  • organisational cultures sometimes prioritise maintaining service delivery over addressing racist behaviour directed at staff 
  • the absence of practical frameworks or guidance leaves newly qualified practitioners uncertain about how to challenge racism 
  • barriers to anti-racist practice occur across several stages of the professional pathway, including education, placements and early employment 

Policy implications  

  • social work education programmes should provide explicit training on recognising and challenging racism 
  • employers should create organisational policies that clearly support staff who challenge racism 
  • managers should provide supervision and support for practitioners experiencing racial abuse from people who draw on care and support 
  • greater representation of ethnic minorities in leadership and academia may improve organisational awareness of racism 
  • organisations should facilitate open discussions about racism in supervision, training and team meetings 

Commentary 

This study examines how newly qualified social workers experience and respond to racism in practice during the early stages of their careers. Through focus groups with 67 practitioners, the authors identify significant gaps in training and organisational support for addressing racism within social work and related health and social care contexts. 

Participants widely recognised that racism exists within social work systems, including in interactions between professionals, in organisational decision-making and in experiences from people who draw on care and support. However, many reported feeling unprepared to challenge racism due to limited training during their degree programmes and early employment support programmes such as the Assessed and Supported Year in Employment. 

The research highlights structural barriers within organisations that limit practitioners’ ability to challenge racism. These include fear of professional consequences, lack of managerial support and workplace cultures where discussions about race are avoided. Some participants reported witnessing discriminatory treatment of people who draw on care and support or colleagues but feeling unable to intervene effectively due to uncertainty about organisational procedures or fear of repercussions. 

For practitioners from minoritised ethnic backgrounds, racism directed at them personally was a common concern. Several participants reported that cases were sometimes reassigned when people who draw on care and support refused to work with a Black or Asian social worker, without the behaviour being challenged. This approach prioritised service delivery but left practitioners feeling unsupported and exposed to further discriminatory behaviour. 

The authors also describe a “layering” of barriers across the professional pathway. As illustrated in the framework presented in the paper, obstacles can emerge from multiple sources, including limited exposure to diversity during upbringing, training programmes that lack focus on race, placements with limited diversity, and organisational cultures that discourage discussion of racism. These combined factors reduce practitioners’ confidence and capability to address racism in practice. 

From a health and social care equity perspective, the findings suggest that failure to address racism within professional training and organisational structures may affect both the wellbeing of practitioners and the quality of services delivered to racialised communities. Strengthening anti-racist education, improving organisational accountability and supporting practitioners to challenge discrimination are therefore important steps toward more equitable health and social care practice. 

Addressing inequalities in dementia diagnosis and care 

A national study exploring practical solutions to reduce inequalities in dementia diagnosis and care across England, drawing on workshops with people with dementia, carers, professionals and third sector organisations.

This study uses the term inequalities. In this Evidence Hub, inequities is used where differences in access or outcomes reflect avoidable and unfair structural barriers in health and social care. 

Key messages 

  • people with dementia and their carers experience multiple inequalities affecting diagnosis, access to care and support 
  • these inequalities arise across three levels: individual characteristics, community and social networks, and wider societal and system factors 
  • stakeholders identified a range of potential solutions focused on strengthening community support and improving health and social care services 
  • proposed interventions included dementia link workers, improved workforce training, community awareness programmes and culturally appropriate services 
  • stakeholders emphasised that no single intervention can address inequalities in dementia care and that coordinated actions are needed across multiple levels 
  • improving integration between health and social care services is essential to support people after diagnosis 
  • increasing public awareness and reducing stigma were identified as priorities for improving help-seeking and earlier diagnosis 

Policy implications 

  • develop link worker or care navigator roles to help individuals and carers navigate services and support after diagnosis 
  • improve integration and communication between health and social care services 
  • increase workforce training to improve dementia knowledge across health and social care settings 
  • create clearer career pathways within the social care workforce to support recruitment and retention 
  • expand community awareness programmes and dementia-friendly initiatives 
  • improve culturally appropriate services and accessible information for diverse communities 
  • strengthen national coordination and accountability to reduce regional variation in dementia care 

Gaps 

  • the proposed solutions were identified through consultation and require further evaluation to assess effectiveness 
  • people living with dementia were less represented than carers and professionals in the workshops 
  • some demographic groups were under-represented in the consultation process 
  • there is limited evidence on the long-term impact of many proposed interventions 
  • further research is needed to evaluate the cost-effectiveness and scalability of suggested solutions 

Commentary 
This study explores practical ways to address inequalities in dementia diagnosis and care through a national consultation involving people with dementia, carers, professionals and community organisations. The consultation involved 131 stakeholders who participated in workshops across England to discuss the barriers people face and identify possible solutions. 

The findings show that inequalities in dementia care arise from multiple interacting factors. These include individual circumstances such as income or ethnicity, community-level influences such as stigma or limited social support, and wider structural issues such as service availability and coordination between health and social care systems. 

Many of the proposed solutions focused on improving support after diagnosis. Stakeholders highlighted the potential role of dementia link workers or care navigators who could help people and their families understand their diagnosis, navigate services and access appropriate support. These roles could help address some of the structural barriers that currently create inequities in access to care. 

Community engagement was also identified as important. Participants emphasised the role of dementia-friendly communities, peer networks and local organisations in raising awareness and reducing stigma. Improving understanding of dementia within communities may encourage earlier help-seeking and improve access to support. 

Workforce development was another key theme. Stakeholders identified the need for better training for health and social care professionals, as well as clearer career pathways within the social care workforce. Improving workforce knowledge and stability may help reduce inequities in the quality and availability of dementia services. 

From a care equity perspective, the study highlights that inequalities in dementia care often reflect avoidable structural barriers within systems and services. These inequities can affect who receives a diagnosis, how quickly support is provided and the quality of care available after diagnosis. 

Overall, the study suggests that reducing inequities in dementia care requires coordinated action across multiple levels. Interventions targeting individuals, communities and health and social care systems need to work together to ensure that people living with dementia can access timely diagnosis and appropriate support regardless of their background or location. 

Digital skills and learning in the social care workforce

A survey study examining the digital skills, experiences and attitudes of the Northern Ireland social care workforce towards technology for learning and development.

Key messages 

  • many social care workers preferred face-to-face training over digital formats 
  • digital skills varied widely across the workforce 
  • older age was associated with lower digital skills and confidence 
  • higher confidence with technology was linked to greater engagement with e-learning 
  • lower digital skills were associated with reduced interest in online learning tools. 

Policy implications 

  • basic digital skills training is needed across the social care workforce 
  • blended learning approaches may support engagement across age groups 
  • workforce development strategies should address confidence as well as skills 
  • digital capability is increasingly important for learning and service delivery. 

Gaps 

  • findings are specific to Northern Ireland 
  • survey data may not capture depth of lived experience 
  • limited exploration of organisational support for digital learning 
  • changes in technology use since 2020 are not reflected. 

Commentary 
This study highlights the uneven distribution of digital skills within the social care workforce and how this shapes engagement with learning and development. Preferences for face-to-face training suggest that digital learning cannot be assumed to be universally accessible or acceptable. 

The relationship between age, confidence and digital skill points to the need for targeted support rather than uniform approaches. Where workers lack confidence, digital learning tools may become barriers rather than enablers of professional development. 

From a care equity perspective, disparities in digital capability within the workforce risk reinforcing inequities in access to training, progression and job security. Workers with lower digital skills may be excluded from development opportunities as learning increasingly moves online, affecting retention and workforce resilience. 

Overall, the study stresses that digital transformation in care depends on investing in people as much as platforms. Supporting equitable access to skills and training is essential if technology is to strengthen, rather than fragment, the social care workforce. 

The state of the adult social care workforce in England

A national overview of the adult social care sector and workforce in England, including recruitment, retention, pay, demographics and training.

Key statistics 

  • 24.2% turnover rate in adult social care between April 2023 and March 2024 
  • women make up 79% of the workforce, with men accounting for 21% 
  • 75% of the workforce are British, 19% non-EU and 6% EU workers 
  • pay levels vary by role and region 
  • workforce projections indicate ongoing recruitment pressures. 

Key messages 

  • recruitment and retention remain persistent challenges across adult social care 
  • the workforce is predominantly female 
  • international recruitment continues to play a significant role 
  • pay, qualifications and access to training vary across roles and settings 
  • workforce demand is expected to remain high in future years. 

Policy implications 

  • action on pay and progression could support retention 
  • workforce planning should account for demographic composition and future demand 
  • training and qualification pathways remain important for workforce sustainability 
  • reliance on international recruitment has implications for workforce resilience. 

Gaps 

  • links between workforce conditions and care outcomes are not fully examined 
  • longer-term impacts of policy changes require ongoing monitoring. 

Commentary 
This report provides a comprehensive snapshot of the adult social care workforce in England, highlighting the scale and persistence of recruitment and retention challenges. High turnover and continued reliance on international recruitment underscore the fragility of workforce supply. 

The demographic profile of the workforce is striking. A predominantly female workforce, combined with variations in pay and progression, points to long-standing structural issues in how care work is valued and rewarded. These patterns shape both workforce stability and career sustainability. 

From a care equity perspective, the findings raise questions about who bears the burden of workforce instability. Low pay, high turnover and limited progression disproportionately affect groups already overrepresented in the sector, including women and migrant workers. These have consequences for continuity, quality and fairness of care for people who rely on services. 

Overall, the report highlights that addressing workforce shortages is not only about numbers. Improving equity in pay, conditions and opportunity is central to building a stable adult social care workforce and ensuring that care is delivered consistently and fairly across England. 

The costs of care in residential homes for older people

A study examining care work in residential homes for older people, focusing on working conditions, care routines and the relationship between workforce culture and quality of care.

Key messages 

  • quality of care in residential homes is closely linked to available resources 
  • workforce culture shapes daily routines and philosophies of care 
  • care workers play a central role in translating organisational priorities into practice 
  • time pressures influence how care is delivered to residents 
  • divisions of responsibility within care homes affect staff experience and care outcomes. 

Policy implications 

  • resourcing levels directly affect the capacity to deliver high-quality care 
  • workforce culture should be considered alongside staffing numbers 
  • clearer allocation of responsibilities may support safer and more consistent care 
  • time allocation per resident is a critical factor in care quality. 

Gaps 

  • limited exploration of how responsibilities are divided across staff roles 
  • need for further research on time pressures and their impact on care delivery 
  • findings are based on residential care settings only 
  • wider system-level influences on care home resourcing are not examined. 

Commentary 
This study provides a detailed account of how care work is organised and experienced within residential homes for older people. By focusing on everyday routines and interactions, it shows how care quality emerges from the interaction between resources, organisational culture and staff practice. 

The findings emphasise that good care is not solely a function of individual commitment. Workforce culture and material conditions shape what care workers are able to do, how time is prioritised and how responsibilities are distributed across teams. 

From a care equity perspective, the study highlights how under-resourcing and time constraints can create uneven care experiences for residents. When staff are required to ration time or negotiate unclear responsibilities, some residents may receive more attentive care than others. These dynamics reflect broader inequities in how care is funded and organised, rather than individual failings of workers. 

Overall, the paper stresses the importance of viewing workforce conditions as central to equitable care. Ensuring fair allocation of time, clarity of roles and adequate resources is essential if residential care homes are to provide consistent and dignified care for all residents.

The impact of digitalisation on mental health care

A review exploring how digital technologies are transforming mental health care, including their potential to improve access alongside barriers related to workforce readiness, trust, and unequal access to digital resources.

Key statistics 

  • between 38% and 78% of people with severe mental health conditions report seeking mental health information online 
  • 90% of UK households had internet access at the time of the study 
  • smartphone ownership among UK adults increased from 52% to 85% over a five-year period 
     

Key messages 

  • digital technologies are increasingly used for mental health support, including self-monitoring, online information seeking and remote interventions 
  • co-production with clinicians, frontline staff and people with lived experience is important to design tools that are relevant and usable 
  • digital tools can improve access to support, particularly for people who may not engage with face-to-face services 
  • there are significant barriers to adoption, including lack of staff training, limited digital literacy and unequal access to technology 
  • concerns about data privacy, confidentiality and how information is used can reduce trust in digital platforms 
  • some staff and service users are concerned that digital tools may weaken therapeutic relationships or replace face-to-face care 
  • digital interventions are developing faster than the evidence base, creating challenges for evaluation and implementation 

Policy implications 

  • invest in digital infrastructure and training across the health and social care workforce 
  • embed co-production approaches in the design and implementation of digital mental health tools 
  • develop clear governance frameworks for data security, privacy and ethical use of digital health data 
  • ensure digital tools are used to complement, not replace, face-to-face care where needed 
  • address digital exclusion by improving access to devices, internet connectivity and digital skills support 
  • support ongoing evaluation of digital interventions to ensure they are effective and safe 

Gaps 

  • limited high-quality evidence on long-term effectiveness of many digital mental health interventions 
  • digital tools are often developed without a clear theoretical framework explaining how they work 
  • lack of consistent evaluation methods, with traditional trials often too slow for rapidly evolving technologies 
  • limited research on how digital approaches affect therapeutic relationships and care quality over time 
  • insufficient focus on how digital exclusion affects access for different population groups 

Commentary 
This paper looks at how digital technology is changing mental health care. It shows that more people are using the internet and smartphones to find information, track their symptoms and access support. For some people, this can make it easier to get help, especially if they feel uncomfortable with face-to-face services or live in areas with limited provision. 

However, access to digital care is not equal. While many people now use the internet regularly, not everyone has the same level of access, confidence or skills. Some people may not have reliable internet or devices, while others may struggle to use digital tools. This creates a risk that digital approaches could widen existing inequities if they are not designed and implemented carefully. 

The paper also highlights concerns from staff and service users. Some worry that digital tools could reduce human contact or be used as a cheaper alternative to proper care. Others are concerned about how personal data is collected and used. These concerns can affect trust and willingness to engage with digital services. 

Another key issue is the gap between how quickly digital tools are being developed and how slowly they are evaluated. Many tools are introduced before there is strong evidence on how well they work or who they work best for. This makes it harder for services to know which tools to adopt. 

From a health and social care equity perspective, digital technology has both potential and risk. It can improve access by reaching people in their everyday lives and offering flexible support. At the same time, if issues like digital exclusion, workforce readiness and trust are not addressed, it may reinforce existing inequities. 

Overall, the paper suggests that digital mental health care should be developed alongside, not instead of, wider investment in services and support. A balanced approach is needed so that technology improves access without reducing the quality or equity of care.