Dystopian scenes across the country of patients lying for hours on the floors of A&E, queues of ambulances with patients waiting days to be moved to a non-existent ward bed, and medics at breaking point. It’s hospitals that have dominated the nation’s headlines for months.
But experts say that the chaos unfolding in our NHS is a symptom of a much bigger problem. It’s one that will take years - and untold millions - to solve. The future of the NHS is intrinsically tied to that of social care, say doctors on the ground and health service leaders alike.
In January, the government revealed a £200m plan to buy care home beds for the NHS. It’s not going to work, say doctors. They tell the Manchester Evening News why.
What is social care for?
Social care is regularly limited to a vision of elderly people in care homes and care visitors to the frail and medically vulnerable. But social care - as vague as that term is - is far more all-encompassing in who it looks after.
Social care covers hospital patients who need help on being discharged after an operation, support for people with physical or learning disabilities wanting to live independently at home, therapy for young people from difficult familial backgrounds or those in foster care - the list goes on. If you need checking up on even as little as once a week, chances are, that could very well fall under the social care umbrella.
Thousands of staff missing - and people needing help getting missed as a result
Those within the social care sector have spent years crying out that the system is chronically underfunded and understaffed. Figures from the annual Skills for Care report showed that the number of vacancies in social care had shot up by 52 per cent to 165,000 unfilled posts in 2021/22 – the largest annual increase since records began in 2012/13.
Jobs that are frequently national living wage, with no sign of a pay rise or career progression for difficult work, have led to a recruitment crisis. Experienced staff leave the profession, young people joining see no future in social care and leave quickly, and the declining number who stay see their caseloads and stress levels climb to worrying heights.
It’s the people needing care who suffer the consequences, explains Madaline Taylor, a specialist therapeutic social worker on the fostering team at Oldham Council.
"It could get quite dire if you don't have enough foster carers and enough specialist workers, and just consistent workers. Consistency, regular visits, regular communication from professionals,” she explains.
“If workers are overwhelmed with cases, overstretched - it's obvious isn't it? Things will get missed and our children won't be getting the service that we aspire to give them and what they should be getting.
“We don't want them to miss out on getting timely provision and timely support. If it was support from our therapeutic team, we want that as early as possible, rather than letting a child deteriorate."
"Most people are in this work because they want to make a difference, they don't take it lightly,” continues Ms Taylor, who says that the lack of career progression can make workers feel like they are stuck. “To feel that you're struggling against the tide or you're not making a difference, you need those rewards. Otherwise, it can be very stressful and just lead to a workforce that's lacking in motivation.
“You've got to have the tools to do the job. [A pay rise] helps morale but also it's not just about the money, it's about having good career progression.”
Hospitals are 'creaking'
This winter so far has been characterised by creaking A&Es with patients lined up outside waiting for beds. Among the reasons for their long waits are hundreds of patients across Greater Manchester who have been assessed as medically fit to go home but cannot leave wards - routinely for as much as ‘six weeks’ according to one Greater Manchester A&E consultant - as there are not enough social care staff to take on new cases.
Some patients must have a social care package in place before NHS hospital staff are allowed to discharge them while ensuring their safety. The care plans are necessary to monitor a patient’s wellbeing once they leave hospital, help them around the house as they try to resume independent living, or support them emotionally as they progress with treatment at home instead of on a ward.
Mark Fisher, the new chief executive of NHS Greater Manchester, told the M.E.N the huge number of people who are waiting discharge for a variety of reasons, including social care problems, is ‘making the system creak’.
“The NHS is absolutely reliant on social care, a large number of the problems in the hospitals is because we cannot discharge people from the hospitals into domiciliary and other settings,” he said.
"For every week you're in hospital, you lose some percentage of your functionality, like making yourself a cup of tea, and it's because you're in bed because they don't want you walking around because you're in hospital and you're in your pyjamas, not getting dressed."
'Buying care home beds won’t work, Prime Minister'
In January, the NHS was given £250m by the government to buy thousands of beds in care homes. It was hoped - and hyped up by the government - that the move would free up 2,500 hospital beds so patients can be admitted more quickly from A&E as around 13,000 patients across England were medically fit to go home.
The reality of that plan is much different, according to Greater Manchester’s medics, whom the M.E.N. is not identifying. There is no point buying beds in care homes when there’s no more staff available to look after the patients who will go there, they say.
“In my area, we do have some capacity in care homes, around one-third of our care home beds are empty but it’s not just that,” said one GP.
“You have to recruit staff, you can’t just move people to empty beds and not have the staff to look after patients. It’s not a quick fix.
“You might be able to move a few patients out of hospital but not as many as is being expected nationally, you need the staff. Throwing lots of money at it isn’t going to fix the problem. People aren’t sitting and waiting, not working - this needs a workforce plan.”
“Buying the care home beds might release the immediate block but if you haven’t got the staff, resources or infrastructure to make sure the patient gets the care they need, it’s kicking the can down the road,” agreed an A&E consultant.
We're living longer, demand is only going to grow
Staff numbers are stagnating, but the demand on social care is growing fast, says Councillor Lisa Smart, who sits on Stockport’s adult social care and health scrutiny committee. “People with a learning disability are likely to need support for the whole of their lives, and their needs may change because they'll have medical and mental health challenges, the same as anybody.
“But the care and support that they will want will possibly be different from somebody without a learning disability.
“We're all living longer and that means people who historically had a condition that meant their life expectancy was shorter are living longer and needing more care with conditions like diabetes and dementia. There's also lots of other people who are adults with a learning disability or autism or something else that means they need extra support.
“The demand on social care, the demand on council services is growing in all sorts of directions.”
Cost of living crisis creating more chaos
More people growing older with more care needs costs more money. That’s made yet more expensive by the cost of living crisis. These problems combined make a pay rise for staff appear more unlikely than ever as care home owners say they are struggling to balance the books.
“The demand for services will increase and we have to manage that - it’s not about sending people straight into care, it’s about helping them to live as independently as possible for as long as possible. That costs a lot of money,” explains Andy Morgan, Bolton Council’s cabinet member for adult and housing services, himself the managing director of a care home company.
“[Bolton Council's] aspiration is to get providers to reward staff appropriately, but if [the council] can’t afford to pay for the fair price of care then we can’t reasonably expect providers to pay [staff a higher wage].
“All our staff are having problems getting to the real living wage, but as businesses, providers are facing the same pressures with utilities, cost of living, food. It’s a vicious circle.”
Without wage increases, the cost of living crisis is yet another reason for staff to leave the sector. "The vacancy rate and the turnover rate continues to increase in the social care workforce,” says Coun Smart. “In Stockport, lots of the carers who work in the borough don't live here so cost of living challenges, like transport to work, make it more difficult. If you have to pay more for petrol to get to work, why would you try and travel further?
“When you’re competing with supermarkets advertising for the same wages, you can understand why people might choose a quieter life.”
Councils spending substantial amounts on agency workers - they are only a 'sticking plaster'
Across the country, including Greater Manchester, cash is being spent on agency workers to cover social care shifts. “The amount being spent on agency workers is substantial across the system at the moment,” says Coun Smart, who believes temporary workers who can leave at short notice are a ‘sticking plaster’ on a long-term problem.
“If you want to fix the NHS, you have to fix social care.”
"We like to keep children in the same locality and same school, things like that have a massive impact. No detriment to agency workers but if we can lessen the external payments to other agencies and agency workers, because we've had a lot of that on the teams and I've seen in my time how that can destabilise, [it will be better for the children and families,” says specialist care worker Madaline Taylor.
“If we're spending a lot of money on agencies and out-of-borough foster placement, it's so costly. It's not just the cost monetarily, it's the cost to children and families because then there's a geographical distance, the impact is more significant on a child if they have to move school and then change friends. It's a massive thing for the child's life.
"By saving all that money that we're spending, and bringing it back in and for our own provisions, that's got to be a good outcome.”
For children, if you start prevention measures early to stop any deterioration, there might not even be a need for social care later on in life, which would relieve some pressure on the system. But things are currently so short staffed, those needing help might deteriorate before they get it.
“You don't want to keep fighting fires. More prevention is always going to be more helpful in the long run," said Ms Taylor. "That requires investment."
“If you can get a stable workforce that's permanent and that knows the families - in my experience, that's what matters. You get to know your children and your families, and it's not a succession of people coming and going.”
We have the ideas - just give us the money and we'll fix it'
The NHS’ fate is dependent on social care and the social care sector is desperate for money, say those within the field, with one A&E consultant saying that money should come from the same place as the NHS’ funding so social care is treated with the same value as the health service.
“I think it’s in the NHS’ interest, therefore, to look at resources and see what it can do to help,” says Mark Fisher, Greater Manchester’s NHS chief executive, who feels the NHS and social care should be a ‘single system with a single workforce’.
“I think a lot of the issues in social care are to do with it’s workforce and pay rates and deep-seated problems. We’re not going to solve all those overnight.
“We are at least looking at this thing in a very integrated way and we’re piloting and trialling really interesting ideas which will help a lot in due course.”
“Our [NHS] realises and knows that without social care, their jobs become a lot more difficult. We can’t do it without the NHS supporting us,” says Bolton's Coun Morgan.
Mr Fisher and Coun Morgan both suggest that creating career paths where staff start out in social care, before working their way up to nursing roles within the NHS, would give them that crucial sense of progression.
In Tameside, "social care staff do some of the jobs that district nurses do,” continued Mr Fisher. “That means we can pay those staff more, we can give them some sense of career progression, increase their job satisfaction and the retention.”
Bolton Council is also ‘striving towards the real living wage’ for its social care workers and has put forward budget proposals of 20 per cent above the minimum wage, adds care home owner Andy Morgan, but ‘for every 10 pence increase over the minimum wage it costs the local authority £730,000. It’s a massive increase’.
“We need to give the same recognition to social care staff as the NHS gets. That’s key. We need to work as a whole system to make sure that people get really good training in social care, they work in the system for four, five years, then they progress through the NHS.
“There’s so many vacancies in the social care sector, the bottom line is that if the social care sector fails then the NHS will fail.”
The Conservative councillor is urging his own party in government to send money up to Greater Manchester, but not dictate how it should be spent: "What we need is the money, we need the [government] to send us the money, we will manage it as a system, we don’t need them to tell us what’s best for Greater Manchester.
“We’re the best placed people to do that, just give us the money. We’re telling [the government] we’re under budget - the local government association, which is all the political parties, is saying social care is at a real critical point.
“We know what we need to do locally and we’re telling [the government] what we need.”
Over in Oldham, the council has taken it upon itself to tackle the crisis head-on - to the tune of an investment of almost £15m to try and improve pay, conditions, training and career progression.
Councillor Amanda Chadderton, leader of Oldham Council, plans to lobby the government, calling for action to tackle the chronic shortage of social workers, in what she called a "national problem that needs a national solution."
In the meantime, the £15m commitment will improve the situation locally, it is hoped. "This investment will enable us to recruit 50 extra social workers to reduce our dependence on much more expensive agency staff; bring in more social care support workers - enabling our social workers to spend more time with families - and also encourage the best social workers to stay here, with a new £2,000 retention payment to reward loyalty,” continued the council leader.
"We'll also be increasing payments to foster carers; creating a residential care home right here in Oldham for children with disabilities, to reduce the need for out-of-borough care, as well as creating move-on accommodation options for young people aged over 18 - preparing them to live well independently.”
But while some say the NHS should syphon off some of its funding for social care, and others are taking on the responsibility of fixing the local social care market, Lisa Smart says that a systemic overhaul is long overdue. Charities are now frequently filling in for services that should be provided by the government, claims Coun Smart.
“So the government is putting the expectation on councils that they'll raise council tax by the maximum amount then they'll use that money to spend on on social care," she told the M.E.N. "That model is broken and has been broken for a really long time. Not being able to provide the social care people need has a massive impact on the health service but also organisations like the police, who are getting called out for reasons that aren't really criminal behaviour.
“That has been a slow shift, but a noticeable shift, that increasingly services are being provided by charities that might get funded to deliver a project or be commissioned to deliver a service by the council."
Responding to the M.E.N.'s interviews for this piece, a Department of Health and Social Care spokesperson said: “We are investing up to £7.5 billion over the next two years to support adult social care and getting people who are medically fit out of hospital – the biggest funding increase in history.
"We are also promoting careers in care through our annual domestic recruitment campaign and are investing £15 million to increase international recruitment of carers. Most paid carers are employed by private sector providers who set their pay and conditions independently, but the government has raised the national living wage by 9.7 per cent to £10.42 an hour for workers aged 23 and over, and is working to reduce vacancies.”
Looking to the future, it has to be a combination of national and local efforts - and there are no quick fixes, says Oldham social care worker Madaline Taylor. “It’s a national issue… By making things like pay and training more attractive and supportive, I think [Oldham is] wanting to become the place where people would want to work.
“It will take time because things can't just be put in place. I think most of us recognise that. But the start has been made. There's no false hope here. We're doing all we can with what we've got.”
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