Professionalising the workforce

Featured article - 21 November 2021
Sir David Behan, Chair, Health Education England

Care workforce

This speech was given by David at the Care Talk and SCIE 'Coming out of Covid' conference, November 2021

Good morning. It is a pleasure to join you today for this timely and important conference.

We know that good social care transforms people’s lives. It sees people as individuals and enables people to live independent and fulfilling lives. Personalised care helps older people maintain their independence and helps younger adults live the lives they wish to lead. It provides people who use services with choice and control.

Personally I like the way the Social Care Future vision describes social care :

Supporting us to live in a place we call home, with the people and things that we love, in communities where we look out for one another doing the things that matter to us through care and support that is inclusive, accessible and innovative.

I would add to this vision the importance of care and support that is: kind, safe, high quality and well led. Is this the reality for all who use social care? Whilst the quality of most of the adult social care is assessed as good by CQC in their most recent “State of Care” report there is still far too much variation in quality and far too many people who use care express their dissatisfaction with it.

The current system of care was designed in the middle of the 20th century to meet 20th century needs. As we enter the third decade of the 21st century those needs are changing. The diseases which killed us in the 1950s have been largely eradicated; now the diseases which kill us are largely lifestyle driven: obesity, cancer, cardiovascular. These conditions present different challenges for the delivery of health and care services. The good news is that we are living longer but, healthy life expectancy is not keeping pace with life expectancy; we are taking into our later years a range of complex, comorbid conditions such a frailty, dementia and a range of cardiovascular related illnesses which are driving demand for both health and care services. This is not just a challenge for services for older people as complexity and co morbidity are also very apparent for children and working age adults too. These demographic drivers of demand are already “baked in” to our society. These changes in demand have implications for both the models of service and the models of care that will be required to support people in the future. Advances in science and technology will increasingly contribute both to the way we maintain our health and wellbeing as well as to the way in which care and support will be delivered. One of the most significant implication of these developments is, in my view, for the education and training of the workforce. The degree of skill required to support a person living with advanced dementia or a person with profound leaning disability and challenging behaviour or the younger disabled adult who requires peg feeding is considerable.

In this third decade of the 21st century it is essential that we make a substantial investment in the education and training of the workforce. In regulated services lifting and handling training is mandatory, yet in services for older people training in the care and support of people living with dementia is not - yet over 70% of care home residents are assessed as living with dementia.

After a 25 year wait for Government reform a very welcome start was made with the publication of “Build Back Better: Our plan for health and social care” last month.

The announcement focused on funding reform with an additional £5.4 billion allocated for social care funded from a rise in national insurance contributions. The money will be used to introduce the “Dilnot” type reforms to the cap and means test. Alongside the funding announcement was a very important recognition of the importance of the need to invest in the education and training of the social care workforce.

We now await the publication of the two promised white papers later this year: one on social care reform and one on integration between health and social care which are essential to understand the scale of the Government’s ambition for social care.

The Health and Care Bill currently going through Parliament also presents an opportunity for further improvement in the approach to workforce.

Social Care is a high skill role. The investment in the workforce is key to reform.

What I have learned over my career is the importance of investing in and, engaging the workforce. The evidence from any sector is that a workforce that is engaged, that is valued, that is listened to and treated with compassion and kindness will be high performing. The business case for this is inarguable- providing “good work” leads to: reduced sickness rates, reduced turnover, and improved quality. The key to better outcomes is through the engagement of, and investment in, the social care workforce. Alongside the business argument there is an economic argument to invest in social care: the scale of the sector means it creates a range of employment opportunities benefitting local communities and local economies. There is also a moral argument about the value we place on caring as a society.

So, what do I want to see emerge from the white papers and other reform opportunities? What needs to happen?

I argue that we need to move from crisis to a better future where we can secure the workforce for the future. In order to achieve these improvements in the recognition, value and reward of the social care workforce are key. There are three key interconnected policy initiatives.

Firstly, the development of an education and training curriculum which goes way beyond the current statutory minimum of the Care Certificate and enables the workforce to acquire the knowledge and develop the skills required to care for those people who have complex needs. The education and training must reflect the needs of the people who are supported by services. It must also offer the opportunity for care staff to develop a career and continue to develop their knowledge and skills by moving through different levels of education – levels 2, 3 ,4 and beyond. I would link this education and training framework to that of health care assistant, nurse associates and nurses’ education and training. In this way it will become possible for people to pursue a career in health and care moving between services. Something which is not currently available. As we look towards a future where multi professional teams work together in integrated services to meet the complex needs of people who use services the health and care workforce needs to be seen as one and not as two. Whilst some in social care will view it as controversial my argument is that if we start this discussion from the needs of those who will require services then this is a logical and an essential development. I am aware that there are risks to this approach namely that a bio medical model could dominate, and a psycho-social model is squeezed out but with care and careful planning my view is that this can be addressed. The development of ICSs and the forthcoming integration White Paper present opportunities to pursue this approach.

Secondly, the introduction of a register of staff who work in social care. Such an approach would be a recognition of the importance of the role those who work in social care play and the skill they possess. Registration would recognise, and value, care staff in the same way as it provides status and recognition for the staff who work in other sectors- health, education, the law, finance etc. It could also provide reassurance and confidence to those who use services that their workforce meets clear and transparent standards of knowledge, skill, values and behaviour. The acquisition of education and training would be a key requirement of registration. This is not a quick fix, and it will require long term reform in developing the education and training infrastructure for social care but it would create the pathway for a year-on-year increases in the proportion of social care workforce who secure qualifications and in this way I would see education and training driving improvements in the quality of services. It would also require primary legislation. Wales, Scotland and Northern Ireland have all introduced registers for social care staff and these examples can provide helpful learning to those of us working in England. Again, for some, professionalising the workforce in this way will be seen as controversial inhibiting flexibility in services by introducing the dead hand of regulation. I understand that argument; however, I see a register of the social care workers as a way of increasing both the recognition and status of the workforce and as a way of driving continuous improvements.

The third initiative is the development of strategic workforce planning for the health AND care workforce. In headline terms the social care workforce comprises 1.5 million workers employed by 18,000 organisations with 95% of provision in the independent sector. It is a £33 billion industry yet there is little strategic workforce planning taking a long-term perspective on future workforce demand and supply. Employers have a responsibility to secure their workforce but in such a pluralist and devolved sector some central mechanism which takes a longer-term foresight approach to future demand and supply is, in my view, essential. I say foresight rather than forecasting because I think it is very difficult to accurately predict the future, but we can anticipate different scenarios that we could, and should, prepare for.

As services develop over the next decade, I envision a range or continuum of care: predominantly people will be cared for at home through a range of services; care at home services; personal budgets; direct payments; there will be a range of housing and support options combining congregate living and care in imaginative ways and for a very few, with the highest level of acuity, there will be care homes. Technology will play an increasing role especially supporting and supplementing the delivery of care in the home. How we plan the workforce for this future will be critical. Helen Whatley when Minister for Care at the DHSC asked HEE to create a strategic framework for workforce planning. That work has now begun, and a deliberative process started on 1st November and will continue throughout the winter months with a final report produced for spring 2022. In HEE we are increasingly working with Skills for Care and we will do so on this commission.

In recent visits to see the Cheshire and Merseyside ICS develop I was struck by the way they are taking a much more integrated approach to planning the work force they will need to meet the needs of their population. I see this as a positive improvement and think that there needs to be national infrastructure to support this local planning for instance, sending signals to schools, FEIs and HEIs on the types of courses that will need to be commissioned to ensure an adequate supply of staff who are able to develop a career . I would argue that this formal role of strategic workforce planning for health and care should be given to HEE working with Skills for Care.

So, improving education and training, registering the workforce and developing strategic workforce planning are designed to better value and recognise the workforce. This will require a greater investment of resources in the workforce. The £500 million announced in Building Back Better: Our plans for health and social care is a very welcome starting investment and further investment will be required if we are to make a step change and deliver a sustainable health and care sector.

I have covered recognition and value and I want now to turn to reward.

We clapped for carers last year but many of them said “don’t clap for us, reward us, recognise us and pay us more”

The excellent Skills for Care in their excellent State of Care report 2021 have calculated that there are over 120,000 vacancies in social care and the recent CQC State of Care report highlighted how this was increasing as many social care staff moved into hospitality and retail sectors who were offering better pay. The increase in the National Living Wage as announced as part of the Spending Review is very welcome but if we are to deliver the vision of a “high skill, high wage economy” we need to build on this.

In the longer term the rate of reward for care staff needs to increase to at least be commensurate with health care assistants. This is an argument that ADASS has made. The move to a “fair rate for care” as announced in Building Back Better: Our plan for health and Care could potentially help. This will require LAs to recognise in their fee rates an improvement in the rates paid to the workforce. I am aware of 14 LAs that pay a basic contract price for residential care of between £455pw to £495 pw or between £65 and £70 per day.

This is not just about pay it is also about the dignity of work as demonstrated through terms and conditions such as sick pay, travel time, pension contributions, the flexibility of working patterns. It is also about employers creating “good” jobs; “good work” which people feel is rewarding and where they are valued by those who employ them. The must feel their employment is secure. They must be treated with kindness, compassion, dignity and respect. The development of a more compassionate approach to the leadership of health and care staff is critical. The style and tone of leadership is set by Boards and senior leaders, and we know from service failures how toxic poor leadership is and we also know from outstanding services just how much value compassionate leadership adds. Whilst we are right to look to Government for help, we must also look to ourselves as employers to accept responsibility for the compassion with which we lead and the cultures we create.

The pandemic has raised the profile of social care and its workforce in a way that I cannot previously recall. The Government reform of social care and the ambition to see closer integration between health and social care presents a real opportunity to build on this recognition.

Care workers have said that they want to be valued by society, recognised for the complexity of the work they undertake, the skills they are required to demonstrate and that they are rewarded fairly and appropriately. Investing in the workforce is the key to ensuring the vison of social care that supports people “to live in a place we call home, with the people and things that we love, in communities where we look out for one another doing the things that matter to us through care and support that is inclusive, accessible and innovative”.

Thank you for listening.

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