Future workforce issues in Health and Social Care
This is a paper for discussion, drafted in response to the consultation on the future health and social care workforce. I am a professor emeritus of dementia studies, a consultant on care of older people and registered nurse. I have worked in the NHS, the Royal College of Nursing, the Senior Civil Service Centre for Change and Innovation, a University and now I work in the UK and internationally with a wide range of organisations across the three sector divides; that is, third sector, public sector and private sector. Frail older people including those with dementia are in all three sectors. Even in Scotland about two thirds of those who require care because they are frail and at the end of their lives are with private businesses.
On the range of consultation questions, including how to decide the appropriate number of training places for workers, I have three responses. First, we need to consider what the future models of care will be before we consider the question of how many workers we need. Secondly, there are people in the consultation group who are better qualified to answer the numbers question once we know the model for future provision. I will consider the workforce who mainly care for older people and people with dementia. We will always need staff working in this area, but their jobs in future may be quite different, structured differently, trained differently, regulated differently and paid differently. Third, I am not going to speak on issues of acute care such as specialist paediatric and child mental health care, midwifery and orthopaedics, and all those important things that are not focussed on frail people at the end of life. Nevertheless, it is important to note that health and care for older people is impossible if provided on an acute care model, as at present.
Public Sector v Private Sector – what is our attitude and public perception?
Public sector reliance on private sector businesses such as staff agencies or private care providers is raised as a problem. Many believe that private sector health and social care business involvement is always unethical. However, we are now inextricably bound together because of historical policy actions. Reversal of this is probably unaffordable for the foreseeable future. We need to plan future staffing together.
The relative ease with which agencies can recruit staff is because they offer working terms and conditions which workers prefer. Working for an agency, NHS and former NHS nurses tell me, allows them a better work life balance. Belonging to the NHS would mean they shared responsibility for a system that does miracles daily but is laden with risk and pressure. Psychologically, as agency staff, they can go home at the end of a shift and not feel answerable for failings of the system. Agencies are often portrayed as taking advantage of the NHS. Rather, workers are taking advantage. When the benefits for working for the NHS are outweighed by the disadvantages what should they do? Rules restricting NHS staff from working for agencies in their own time can only go so far in preventing this flow which is not just about pay.
This is to be contrasted with the relative difficulty of staffing in care services. Private sector care worker recruitment and retention is a serious and expensive issue for providers. Businesses are closing because of it. The problem is not only low pay as a direct consequence of high numbers of public sector residents with frugal funding, but also the overwhelming societal disdain for this work. People are even more rude about care workers than they are about agency nurses. There is a level of contempt expressed for care homes by many, including medical staff, in the health system, who do not understand or value care work. They do not recognise that it is financially risky, complex, highly (and sometimes arbitrarily) regulated, and provided in circumstances where the customer (which is often the relative of the beneficiary) is resentful about any need for the service to be means tested and/or paid for, and suspicious that all private providers are profiteers. This is against a background of extreme enmity to care services in the media, which is even more unforgiving about care than it is about the NHS. The relatively soft attitude to third sector and state funded elder care is more based on prejudice than evidence. All three sectors do amazing work for older people, as does the NHS. It just needs change, and attitude changes to go with that.
Who currently provides care for frail older people and why?
Demographic ageing is well understood, but people are sometimes surprised that most of the old people out of the 80,000 with dementia in Scotland live independently at home, often alone. Remarkably, in non-dementia-specialist “ordinary” care homes, up to 90% of the residents have dementia, often not diagnosed. The average length of stay for a resident in a care home in Scotland is probably about eighteen months, and because most of those people die in that care home we might think of a care home as a kind of “dementia hospice”. (The problem of dying people being transferred to hospital from care homes is a separate issue.) It is intriguing that hospice care is mostly revered and eldercare is often denigrated, when their territory overlaps like this.
The value of UK care services for older people in 2016, was £23 billion; so, we can estimate roughly £2.3 billion for Scotland. It has been estimated that 1% of GDP (£15.7 billion for the UK) was spent on care in residential settings at that time. The ratio of “for profit” to “not for profit” to “public sector” for the UK was 12:2:1.5 approximately. The figures are from 2016 and the Commission will get clearer Scottish analysis from Scottish Care, but it is clear that most residential care of older people is “dementia business in the private sector”.
The history is this. Before the NHS there were fewer frail older people, and many were cared for at home by women who were outside the workforce. More women entered the workforce. At one point, middle to late last century there were geriatric hospitals, and then councils started paying for care homes, so long stay hospitals were closed as patients moved out at the end of the century. More people are now living longer. Families/people must now pay for their own care home if they have property or savings amounting to more than about £26,000, and if they don’t move on fast enough to care homes, older people with cognitive impairment impede the functioning of the acute hospital. Now that councils are poorer, they try to reduce their costs by keeping frail people at home for longer, digging harder to find concealed family wealth, letting tighter contracts to the private sector, not rushing to draw people out of hospital, raising the bar for care home entry and reducing the councils’ public sector capacity for this kind of work (because it is unaffordable the way they do it).
What future model of care do we have to “staff up” for?
What is going to happen next, that will help us decide what workforce we are going to need going forward? There are many future contradictory or complementary scenarios. Here is a list of ten, all theoretically possible, not exhaustive, some unpalatable, and some unexpectedly highly likely.
- A large overseas unqualified workforce from a developing country is imported to Scotland to provide low cost basic care in the home, paid by families
- Care of older people becomes less necessary because the longevity trends reverse, or there is a pandemic (statistically overdue?) that decimates the over 85 frail population
- A new life insurance/savings model is introduced to share the risk across the whole population, or across those who can pay the premiums
- Basic income tax rises to circa 50% to provide world class elderly and dementia care for everyone in an increasing cohort of people at public expense
- We return to an increased and increasing number of care homes funded/operated by local authorities through locally increased council taxes
- Care of older people becomes universally free again as we reinstate NHS geriatric and psychogeriatric long stay hospitals, freeing up hospital beds
- Families voluntarily live in multi-generational households to share care of frail elders, to defray the cost of elder care
- It becomes a legal requirement for families to care for their older members, or to pay for that care
- A cure is found for dementia, meaning that a smaller percentage of the old will be dependent, and only the frailest older people will need care for a short time
- Euthanasia gives people the choice of using any personal resources in the last stages of life or removing themselves earlier to allow legacy gifting to the next generation
None of these is fanciful. Internationally one sees elements of most of these scenarios, except the return to the tranquil days when there were so few old people, the State could afford to care for them for free. However challenging things seem now in Scotland, it will get harder. Even now, families, the NHS and councils are already facing terrible and expensive choices. The lesson from England is that they are further down the track than us, away in the direction in which we are heading.
The well off don’t need to worry. The very poor have known for a long time that they are in trouble. The middle affluent, with a house, and some pension are the voters who are in the dark. They only discover the loss of a legacy or a house if they are in the current minority affected, and they don’t make a fuss because it seems shameful to wish your parent was dead, rather than expensive. No one wants to advertise that they’ve been caught out. However, the more serious issue is if the following generation, already unable to afford a house, unable to afford University education, worse off than their parents, find themselves feeling cheated of the money that was the family’s “investment” in their future. Society will share their problem. How is society going to pay for their care when later they in turn have nothing, no house or wealth, to contribute to the pot? The middle affluent are currently subsidising the councils, with private pay care home beds up to 30% above what councils pay for the same room in the same home and many families paying “top-ups”.
What future staff should we plan for?
In the light of this, it seems overly narrow for the workforce commission to focus on whether we need more of what we have, making changes in what existing professionals can do, and guessing that pay is the thing that makes a difference. If we ask for more money and more of the same professions, we’ll get that, and then be accountable for why we’ve not made the system work because we implied that this was the answer. Staff numbers and pay are used as political currency, not managed economically, efficiently and effectively to deal with the impending problems. This is partly because no one wants to say out loud what is ahead.
The workforce question starts with this. What do you see as the future for the care of frail cognitively impaired older people?
If it is high tax, free at the point of delivery, high quality elder care, political will is needed. Even if that happens, some change in the staffing plan is needed. More health care staff will need to be expert in care of older people, and specialist staff recruited and educated to make sure that the best care is provided where ever the patient wants to be. Investment in thinking what this would look like is unproductive until there is more certainty that this is the future model. More professionals, migrant care staff and big buildings will be the goal. China is reputed to be building 900 bed care homes because the single child cohort families and demographic change means that families can’t care for their own at home any more. Other developed countries have made that work by importing low waged staff from poorer countries who live and work in hard conditions and send their money home.
If we accept the burden is to continue to increasingly fall on families, we need create NHS and care system staffing that will help people start immediately to prepare for the future.
The job of health and social care staff may be to
- Make people aware from their earliest youth that caring for their own older relatives will be a practical requirement, if not a legal or moral one (school nurses and workplace occupational health education programmes?)
- Educate people on how to keep their older relatives well and independent for as long as possible, including how to plan arrangements if you must live away from them, or don’t like them. (More knowledge and understanding for trusted professionals such as GPs on this)
- Educate older people on how to stay well for as long as possible (OT, physio, nurses)
- Assist with financial planning, where people have that luxury (A savings scheme started for a twenty-year-old woman now will give her the choice at fifty of putting her parent in a home, buying care, stopping work to care etc. Without this financial preparation, she faces future disruption and chaos in her career and family life. This is not exactly a health care task, but if health care workers don’t explain to patients and relatives that it is needed, they are affecting their future health care)
- Ensure through planning requirements social housing and private housing that is suitable for multigenerational living, and later life care including communal living, universal access, dementia friendly lighting and flooring (Health care workers involved in planning and design requirements for all new homes and educating families on makeovers)
- Provide on line or telephone support for families for minor illnesses and ailments keeping people outside of hospital (NHS 24 plus, with a case load manager rather than call centre ethos, telephone doctors and other clinicians)
- Intensive falls programmes and other health initiatives to prevent hospital admission of elders (community physiotherapy and occupational therapy)
- Presumption of return to home/family setting after any hospital admission (all rehabilitation staff)
- Safely deregulate or reregulate nursing and care services so that they can be provided by “neighbours” for example, home care where the families live far away (eg, small micro-financed businesses with support and training from health professionals so people who can’t work in other ways provide highly localised services through family contracts or direct payments. “Village agent” model.)
- Support families to care for dying people at home themselves, as once would have traditionally happened. (Currently even care homes tend to export this to the acute hospital unless they have intensive care home liaison support from the NHS)
I finish with a story. My uncle Jim, who had dementia, died in his sleep at home, having been looked after till then by his wife Janey, a retired nurse, and her son who stayed at home with her for a while and did heavy lifting. The morning Jim died, Janey called the GP practice to tell them, not realising that it was still out of hours. The out-of-hours service asked lots of questions, summoned an ambulance and urged Janey to attempt resuscitation. For some reason two vehicles came, along with two sets of paramedics. They took Jim away to the hospital where he took up the time of many staff and administrators, beyond whose care he had already travelled. In days gone by, Janey would have laid him out nicely and called the funeral director. That’s what her mother and grandmother would have done. We need to turn that clock back and learn not to need health and care staff for everything. Learning how to do those things can only come from those staff who have been holding all that knowledge close and doing things for them.
The health and social care workforce of the future probably needs to be made up of people who can co-ordinate family members doing self-care, and give financial planning advice, and help with purchase of tools, techniques and equipment, and design of homes, to face the recognition that this is what the future holds for us. They’ll need family therapy and communication skills. They may work from a call centre doing video calls and providing information and advice. They won’t be doing twenty-minute house calls on large cohorts, because that is unacceptable. There will be more support for family care and direct care will only be provided for desperate cases.
We could start immediately because there are families now who would rather pay for this pattern of care than take what is currently on offer, which sometimes accelerates dependency and brings forward the date when patients need to draw on family wealth to pay for care home care.
Professor June Andrews OBE FRCN FCGI RMN RGN MA (Hons Glasgow) MA (Nottm.)
What should we do about current problems staffing care homes?
The response to this will come from Scottish Care, but it is well known that nurse shortages are a key area here as everywhere. The blame culture and bad publicity make this work unattractive to the full range of workers, and changing the external perception of care is vital. The responsibility for the cost of training care support workers in the non-statutory sector lies with the provider. Harmonising training and reward across sectors in local areas must be possible.
No matter which future model of frail elder care is adopted, even if it is heavily weighted to family support, there will be a continuing need for care homes for those who can afford it. It is predictable that the use will be specified as either a lifestyle choice, for respite, for overnight or day care, for convalescence, terminal care and for residents who could not be supported at home through temporary illness of the carer or the resident. We need to have medical and nursing staff in those places as the level of frailty and dependency of residents increases, and recognition (through funding) of the value of education of basic staff for staff retention, quality improvement and reduction of adverse incidents.