Timely Discharge Series: Where is homecare heading?

Graham Livingston is the joint owner (along with his wife Alison) and Managing Director of Caremark (Plymouth). Established in 2012, Caremark (Plymouth) is an award-winning domiciliary care provider, rated Outstanding by CQC, and part of the Caremark group of franchised offices across the UK.  

This is the seventh blog in the BGS’s ‘Timely Discharge’ series. We aim to raise awareness of the detrimental effects on older people of being stuck in hospital when they are 'medically fit for discharge'. Our blog series explores the causes of delayed discharges, the knock-on effects to the wider health and social care system, and what needs to change.

From my viewpoint as a domiciliary care provider, I see some significant problems in the current situation and its future trajectory. But there are solutions to these problems, given the right resources, leadership and political will. 

The problems are:  

• Increasing demand for services and decreasing capacity of care workers 
• Recruitment and retention of staff - more difficult than ever before 
• Many skilled managers leaving the sector 
• Recruitment from overseas now restricted 
• Job role undervalued and seen as a low skilled, minimum wage position. Not a career choice 
• Qualifications harder to access under apprenticeship scheme 
• Inconsistencies across the UK - no national recognition for care staff during the pandemic in England, but £500 bonus in Scotland, Wales and Northern Ireland 
• Public perception of social care providers as millionaire fat cats who exploit staff  
• Traditional commissioning models not conducive to salaried pay for staff and not monitored by the regulator (CQC) or anyone else 
• Domiciliary care not seen as integral to the NHS by policy makers 
• Many LA/CCG rates do not recognise true cost of providing services and running a sustainable business. Huge variation across the country. 

Possible solutions might include: 

• Professional registration scheme for care staff in England, as already in place in Scotland and Wales with free, accessible training opportunities 
• Immediate significant funding now to facilitate sector-wide pay increase – model proposed by UK Homecare Association should be absolute minimum standard 
• Make home care zero-rated for VAT – currently domiciliary care providers cannot charge VAT, but have to pay it on goods and services. 
• Terms and conditions on a par with equivalent NHS staff 
• Development of a workforce strategy to address major shortfalls in social care. 

Social care is currently facing a national recruitment crisis due to the perfect storm of Brexit, COVID, low funding, an ageing workforce, and enforced vaccinations. Recruitment has stagnated and funding is not keeping pace with rising costs. Funding must be increased to provide the pay rates required to make care an attractive career choice. 

The current situation is already critical and in need of urgent intervention. The government recognise this with their recently announced plan to “fix social care.” Unfortunately, it didn’t have a short-term plan. The increase in funding in two years’ time is very welcome, but there are no details on what that will look like, as yet. 

This has left many within the home care sector in despair at the lack of foresight and planning from the government. 

Experienced and skilled carers and managers are leaving the sector, and as a result, care packages are being handed back to local authorities and CCGs. Delayed hospital discharges are now commonplace, together with the knock-on effect these cause. 

This is happening now, but what does the future look like if we continue on this trajectory, considering recent government plans and announcements?  

With minimal financial help planned in the next two years, the situation can only deteriorate, and without a sustainable social care system, the NHS will struggle to deliver adequate care for older people. Delayed discharges will become more common and cause blockages throughout the healthcare system with longer waits at Emergency Departments, more ambulances queuing to admit their patients and more cancelled elective surgery.  

Depleted social care provision will affect people with a recognised need for a social care package. Finding a care provider with capacity to take on new clients will prove much harder than at present. A greater burden for care needs will be placed on families and the voluntary sector. Recent comments by the current Secretary of State for Health and Social Care indicate that this may well be part of their thinking. Families may have to make a choice between going to work and caring for a loved one if a care package cannot be found. 

How will those who can’t call upon family or neighbours manage? The consequences don’t bear thinking about but could become very real in the months ahead. 

The introduction of a cap on care costs for any individual, while welcome, will mean that more people will be eligible for funded social care. Higher rates paid by private clients currently offset the low rates paid by local authority and CCG contracts. Unless there is a substantial increase in these rates, the income of care providers will decrease. Increases in National Insurance rates will further affect business sustainability and make it harder to reward staff with the terms and conditions they deserve, thus creating a downward spiral of higher costs, lower income, lower wages and reduced recruitment and retention. All at a time when the industry needs to be doing the complete opposite and increasing care staff provision by 600,000 personnel over the next 10 years to meet the projected demand. 

To avoid the scenario describe above, changes in social care are urgently needed. Without them, the knock-on effects for the NHS and users of care services are significant and the future sustainability of the care sector is in jeopardy.