Only innovation will do

Solving the workforce crisis is the key to improving adult
social care, according to a major inquiry by the King’s Fund.
Melanie Henwood reports.

The prospect of a Labour government that -for the first time
ever – will serve a second consecutive full term, and maybe even a
third, is one that offers the potential for major social policy
development. In seeking re-election, Tony Blair demanded a “mandate
for radical change”, and pledged “real reform” for public services.
Expectations are high. Many of those who have stayed loyal to the
New Labour project have done so only in the hope that, finally, the
pay-off will be there, and that the tough love, prudence and even
frugality of the first term will allow – not profligacy – but real
growth and investment in the NHS, education and social
services.

The second term’s agenda needs to be ambitious and achievable.
In social care some important foundation stones have been laid. In
particular, the Care Standards Act 2000 could mark a sea change,
with a national system for regulating social care and driving up
standards. But more needs to be done, and without urgent attention
the opportunity could be lost. Not only might the promised
improvements fail to materialise, but the twin pressures of an
ageing population alongside a growing workforce shortage could
signal a looming crisis. Clearly, there is no room for
complacency.

As ministers settle down to their new positions, there can be no
honeymoon in which to bask in the rosy glow of success. There is
urgent work to be done, and the report of the King’s Fund Care
& Support Inquiry¹ offers a timely contribution to
add to ministerial red boxes.

The inquiry, chaired by Julia Unwin, was established in spring
2000 to examine the quality of physical, practical and emotional
support given to adults in need of help because of:

– Frailty in old age
– Mental health problems
– Physical disabilities
– Chronic illness
– Learning difficulties
– Aids and HIV
– Drug or alcohol dependency
– Homelessness

The focus was deliberately wide, both in terms of the services
involved, and the potential range of different types of care and
support workers working in settings which include hospitals,
hospices, care homes, community facilities, sheltered housing, and
people’s own homes.

At the heart of the inquiry findings and recommendations lies a
concern with supporting and developing the quality of the
relationship between a million care and support workers, and those
who rely on them for help in having a life. The inquiry set out to
hear the voices of as many different individuals and organisations
as possible. In addition to inviting written submissions and
documentation, a number of “oral evidence” sessions took place, and
a series of meetings were held with service users, and with
carers.

There was much to celebrate in the course of the inquiry. We
were repeatedly struck by the commitment of service purchasers and
providers to improving the quality of care. Innovative approaches
to developing flexible and responsive services were evident, and
yet alongside this was a less positive picture in which many
people’s routine experience of using services is far from
satisfactory. Too often purchasing decisions fail to encourage
flexibility, cost management techniques drive down not only costs
but also quality of care, and training approaches fail to meet the
needs of people providing care and support. Perhaps most
fundamental of all, attempts to improve the situation struggle
against the intensifying problems of recruiting and retaining
employees who bring the right commitment and enthusiasm.

While the apparent crisis in public sector staffing is
repeatedly emphasised by Labour’s pledges to recruit more doctors,
nurses, teachers, and “bobbies on the beat”, there has been far
less recognition of what this means in social care. The campaign
run by Community Care magazine and the Local Government
Association has highlighted the need to raise awareness of the
value of social workers, and has been influential. But radical
change is needed in the value attached to care work that continues
to be viewed (and remunerated) as unskilled work that “anyone can
do”.

Ironically, the very steps that are being put in place to raise
standards in care services (particularly new requirements around
training and qualifications to meet national standards), may have
the undesired effect of creating additional barriers to entry for
prospective employees. The challenges of recruitment and retention
demand a range of imaginative and creative responses.

At the very time when there is a growing need for care, there
are powerful combinations of factors which militate against
attracting vital personnel. In a strong economy with low
unemployment most people have choices about the type of work they
will do and under what conditions. It is little wonder that many
people vote with their feet, and tales of the impact on home care
providers and residential care homes when a new Tesco superstore or
Homebase opens on the doorstep were legion in our evidence
gathering. There is growing competition for a dwindling pool of
labour, not only with the retail sector, but with other areas of
the service sector. In such conditions it is imperative that
workforce planning is undertaken collaboratively between health and
social care. New structures created by the NHS Workforce
Confederations and by the Regional Training Forums established by
the Training Organisation for the Personal Social Services (TOPSS),
offer an opportunity for developing a partnership approach.

Raising the image and status of care and support work is
essential. Poor pay and conditions of employment are unlikely to
help in attracting potential employees from new sources. But other
change is also required. The poor status of the work is – in part –
a reflection of the low status which society attaches to elderly
and disabled people. Fundamental shifts in attitude are therefore
needed at a global level, and will not occur overnight. Nonetheless
inroads are being made, and the National Service Framework for
Older People, for example, is to be welcomed for confronting
age-based discrimination.

The Department of Health has a vital lead role to play in
supporting and encouraging strategies to improve recruitment and
retention, and successful approaches in health and social care
should be widely shared. This is not an area in which there is a
single quick fix, but the evidence to the inquiry underlines the
value of innovative approaches which seek to attract a richer mix
of varied staff, including those who may not fit the conventional
model of care worker. There are opportunities for development at
both ends of the age spectrum – attracting younger people through
the emergence of vocationally related GCSEs, for example. At the
other end of the working life there are untapped resources in the
skills and experience of the early retired and newly retired (both
as paid staff and as volunteers).

The inquiry discovered approaches in which different strategies
were being deployed to attract employees. The successful
recruitment of a more transient group of workers (including young
people in a gap year, or others using care work as a stepping stone
to other careers) can be a valuable component of an innovative
workforce strategy. There is also great potential around developing
and supporting particular communities whether they are of faith,
culture or locality. People are motivated by different
considerations, and those who would not ordinarily be part of the
care workforce may nonetheless be interested in supporting a
community which they care about and identify with. Successful
examples of this approach were seen in the context of support for
particular groups of service users (such as people with mental
health needs, or people with HIV or Aids), and for different
minority ethnic groups, where the concept of interdependency was
especially powerful in motivating support. There is undoubtedly
scope for extending this approach to a wide range of different
types of community in both urban and rural settings.

The inquiry’s findings and recommendations on the care and
support workforce are just part of a demanding agenda which also
addresses:

– Overall investment.
– Raising service quality in terms of improved choice and
control.
– Greater user empowerment.
– Cultural responsiveness.
– Improving commissioning for quality.
– Training and skills development.
– Regulation.
– Management development.

Immediate action is required on a number of fronts by the
government, service purchasers and providers, training
organisations and regulatory bodies. Failure to address the agenda
would be short-sighted. For the millions of current and future
service users and their carers, it could be catastrophic. The
future will always be imperfect, but we believe that the solutions
we are offering have the potential to radically transform the
quality of care and support services.

¹ Melanie Henwood, Future Imperfect? Report
of the King’s Fund Care & Support Inquiry, London, King’s Fund,
2001.

Melanie Henwood is an independent health and social care
analyst, and was secretary and rapporteur to the King’s Fund
inquiry.