An expert panel debates the problems around recruitment and retention in social care at a Nursing in Practice roundtable held in September
A ‘tsunami’ of people might be without care this winter, according to a recent annual report from England’s care regulator the Care Quality Commission (CQC). Social care staff are ‘exhausted and depleted’, CQC chief executive Ian Trenholm has warned, and there are rising numbers of vacancies in the sector. This is a concern across the board in social care, but the highest vacancy rate in England is for registered nurses – it stood at 13.4% in August 2021. This is a five percentage-point increase since March 2020, the CQC’s annual state of health and social care report shows, citing workforce data from the Skills for Care charity.
For the sector as a whole, the vacancy rate among adult social care staff in August 2021 was 8.2%, a 0.2 percentage-point increase since March 2020.
This is a dire situation. As well as managing current challenges, social care needs adequate staffing more than ever as our population ages. Registered nurses are an integral part of the response to this demographic challenge.
Nursing in Practice gathered together a group of 12 leading professionals (see box below) working in and around the social care sector to examine why it is so hard to recruit and retain nurses in the sector, and to thrash out some potential solutions.
The panel discussed longstanding issues but also recent developments, such as the Government’s 1.25% National Insurance hike from April next year, announced in September – the so-called health and social care levy. The levy is expected to raise around £12bn a year, which will mainly go towards clearing the NHS backlog of services worsened by Covid-19, but just £5.4bn of a total £36bn is expected to go to social care over the next three years. The potential impact of the controversial mandate for care workers to be double jabbed by 11 November was also considered.
Panel members brought a high level of passion and determination to the debate, sharing fascinating insights and proposing some great solutions.
The Nursing in Practice roundtable panel
Mark Bird – Transformational lead for independent health and social care sector, RCN
Simon Bottery – Senior fellow, social care, The King’s Fund
Louise Brady – Clinical development lead, Royal British Legion
George Coxon – Care home owner and Nursing in Practice blogger
Jana Harris – Interim head of operations, Hafod
Louis Holmes – Senior policy officer, Care England
Clare Jacobs – National officer for independent health and social care, RCN
Liz Jones – Policy director, National Care Forum
Dr Crystal Oldman – Chief executive, Queen’s Nursing Institute
Swaran Rakhra – Member support manager, Scottish Care
Suzy Webster – Care home network manager, Age Cymru
Margot Whittaker – Director, Southern Healthcare
Why are vacancy rates for social care nurses so high?
‘We’re just not attracting nurses into the market’, says Jana Harris, interim head of operations at Hafod, a not-for-profit provider of housing, support and care services in south Wales. ‘Finding a [social care] nurse is like finding gold dust’. QNI chief executive Dr Crystal Oldman echoes this, saying nursing students often do not see a care home placement as ‘valuable’ to their learning. She explains that, during her 18 years in higher-education roles, ‘we would constantly hear students objecting to being placed in a care home, saying “I’m not going to learn anything”’.
The lack of appeal of care home nursing is not a new problem. Member support manager at Scottish Care Swaran Rakhra says working in geriatrics is not perceived as ‘sexy’. Ms Harris adds that social care is ‘normally seen as a lesser sibling of hospital care’.
Senior social care fellow at The King’s Fund Simon Bottery says that although social care has ‘pretty good membership organisations [they are] fragmented’ and there is no ‘overall body that represents social care more broadly’. The RCN’s transformational lead for independent health and social care sector Mark Bird echoes this, saying individual bodies ‘do a lot of good work, but we still work in isolation’. ‘We don’t sit together, we don’t vocalise it, and we don’t commit as one strength,’ he says.
On the importance of pay, a variety of opinions emerge. Nurses are usually paid more than other care home staff. But Louise Brady, clinical development lead at the Royal British Legion, says: ‘Pay has to reflect the complexity of the skills.’ Ms Harris points out she has lost nurses to hospitals and other organisations that offer higher pay or better training.
A lack of training opportunities certainly seems to be causing problems. Southern Healthcare director Margot Whittaker explains: ‘At the moment, we’ve got nurses who are doing very ad hoc training and I feel very strongly we need to have a [national] training programme.’
Are current factors making the situation worse?
The pandemic has clearly taken its toll. Senior policy officer at Care England Louis Holmes says the recent pressures on homes – which have been severely impacted by Covid-19, particularly at the start of the pandemic – have seen ‘nurses leave the care sector at a very speedy rate’.
Mr Bottery points out nursing homes have lower CQC ratings compared with domiciliary, residential and community care providers. ‘A lack of nurses is impacting on the system’s capacity,’ he warns. ‘There’s a clear link between an inability to recruit [social care nurses] and a lack of quality in the system.’
The panel agree the mandating of Covid jabs is likely to worsen the level of vacancies. The Government’s own statement of impact, released in July this year, estimated 40,000 of the current workers in the sector in England might not take up the vaccine by the deadline, which would mean care homes losing that number of employees. Care home owner George Coxon, although in favour of mandatory vaccination, says: ‘The NHS is soaking up a lot of people who are refusing to be safe and do the right thing.’
Policy director at the National Care Forum Liz Jones asks: ‘Was this practically and logistically the best way to achieve vaccination? It would seem at the moment it probably wasn’t. It is likely we will see members who will lose staff.’ (At the time of this roundtable, no decision had been made on making vaccination compulsory for NHS staff, but on 9 November, the Government announced the mandate would be extended to the NHS in England, with a deadline to have both doses by April 2022.)
Is the situation different in Scotland and Wales?
Covid vaccination is not compulsory in Scotland and Wales. Suzy Webster tells us there was ‘a real concern care staff would leave the sector, which we have suffered very badly from, particularly in West Wales and our seaside resorts – a lot of our staff came over from tourism and hospitality, but sadly people seem to be going back to their old jobs’.
Mr Rakhra adds: ‘I think if we were to go down the route of mandatory vaccinations in Scotland, we would lose a lot more staff.’ (The 9 November decision in England has not been mirrored in Scotland or Wales.)
The devolved nations also face high vacancy rates but are tackling them in slightly different ways. The RCN’s national officer for independent health and social care Clare Jacobs says Wales has started work on a partnership forum, which she says is at an ‘embryonic stage’. The forum will focus on workforce, with representatives from trade unions, senior NHS management and the Welsh Government.
In August the Scottish Government released its consultation for a National Care Service, to change the way social care is delivered in the country. It touches on recruitment and retention, suggesting a national body could oversee this as well as staff training and development. Mr Rakhra says more detail is needed and its effectiveness would depend on funding from the Scottish Government.
Is the English Government doing enough?
A Health and Social Care committee report last October said the budget for social care in England should be increased by £7bn a year ‘as a starting point’ – much more the £5.4bn being pledged. ‘We stand with the health select committee,’ Mr Holmes says. He says the Health and Care Bill, currently going through Parliament and expected to come into effect in April 2022, ‘has some good gestures but is lacking in detail’. Ms Jones is glad there is some investment but says the money from the health and social care levy ‘is not enough’. ‘Social care brings incredible economic value to the country. Social care is a local business.’
Mr Bottery points out the pandemic forced ministers to recognise they ‘actually didn’t really know what was going on [with social care]’. They are now working out the ‘right level of oversight and involvement between national government and local providers’, he says. He tells the roundtable panel this means they now have an ‘opportunity for influence’.
What needs to be done?
There is no dispute that the image of a social care nurse needs to improve and the perception of care homes being the poor relation to hospitals debunked. ‘We really need to have parity with everyone because we’re losing staff to the NHS,’ Mr Rakhra says. Ms Brady concurs: ‘Social care needs to sizzle; we need to really have a strategic branding and marketing campaign.’ Ms Jacobs adds: ‘What we need to be putting out there is that while nurses and nursing in social care do not work with machines that go “ping” that might be considered sexy in highly acute NHS hospitals, the nursing workforce in social care are still delivering highly complex specialist and technical work.’ She stresses that social care is the only nurse-led service – ‘therefore, it is “sexy”, actually’.
Ms Oldman explains universities are integral to helping turn around the sector’s image. It’s about ‘culture change within universities, and working with placement officers and tutors,’ she says. Mentors need to be developed, she suggests: if more students are encouraged to do a placement in a care home with ‘great mentors [they will] want to come back when they qualify’. Ms Jones echoes this: ‘If we can get them early they will stay. Everyone who’s going through nursing training should have some time in the social care sector.’ She believes the sector needs to support universities in placing students in care homes because so far ‘it’s been much easier to get them into hospitals’. Ms Whittaker says: ‘We need to educate the nurses that are currently in post so that they can mentor effectively new nurses coming into the sector.’
Mr Coxon says social care stakeholders must work together to improve the image. ‘We’ve got to unite in a consistent, clear and confident way to promote what is good about social care nursing. It’s about leadership, changing the narrative and promoting the relationship-focused nature of what we do.’
Mr Bird wholeheartedly agrees: ‘We are the people who can really make a difference. But how often do we come together to do that? We never really come together.’ He suggests that although social care is devolved to the four nations, ‘that doesn’t mean we shouldn’t be sharing best practice’. Mr Holmes expresses the view that the pandemic has ‘brought trade associations and representative organisations together’.
Mr Holmes would like to see a visa relaxation for care homes workers, similar to the emergency six-month scheme the Government introduced in October for HGV drivers in order to counter fuel shortages and empty shop shelves. ‘Brexit has had a huge impact on the care sector. They’ve tried to bring in foreign workers for the fuel crisis, I can’t see why they can’t do it for nurses.’ Ms Jones agrees: ‘What would really help as a short-term measure is to add care workers to the shortage occupation list for a temporary period of up to two years.’
Mr Bottery reveals that the King’s Fund and other organisations have been trying to introduce an amendment to the Health and Social Care Bill that would require the secretary of state to conduct an annual assessment of workforce planning across healthcare. ‘I think there’s lots of things that need to happen at that local level or subregional level, but starting at the top [by requiring central government to have a workforce plan] does seem to me one small step forward,’ he says.
The CQC’s report calls for a care workforce plan that considers ‘recruitment and retention, training, pay and rewards’. Certainly, the problem of social care and its ongoing workforce issues are a long way from being ‘fixed’, as Boris Johnson promised they would be on the steps of Downing Street when he became Prime Minister in July 2019. But perhaps there is now evidence that social care is climbing higher up the political agenda. As Mr Bottery says, this now gives the sector an opportunity to bang the drum and call for an effective workforce plan.
Our panel members’ contributions to the roundtable made it clear that, if these organisations can pull together and the Government listens, talk could certainly be turned into action and the social care nursing vacancy rate could finally start to move in the right direction.