Health and care services

Why resolving the crisis in adult social care cannot wait

Adult Social Care in Northern Ireland is in deep crisis which is worsening by the day, writes Pauline Shepherd, Chief Executive of Independent Health and Care Providers (Ihcp).

As care providers we are doing everything we can to meet increasing demand and are totally committed to work with health authorities to rise to the challenge.

Power to People, the Expert Panel Review which was commissioned by our last government, said the social care system is “collapsing in slow motion”.

The report, published in December 2017, contains 16 urgent proposals to address the deepening crisis. Eighteen months later we find ourselves no further on. We understand that the lack of government has meant that many of these reforms cannot be immediately implemented. However, the price of inaction is too high to contemplate. Therefore, the Department must urgently address all those matters which are within its control, and prepare any necessary policy papers and legislative change to ensure that the outstanding matters can be addressed as soon as a minister is in place.

At the heart of the crisis is increasing need which will accelerate still further in the years to come. The next 20 years will see huge rises in the number of people over 65, over 80 and over 85. This will be accompanied by a related increase in the percentage of people living with chronic conditions that will either need care home beds or support in their own homes.

As a result, it is estimated that compared with 2016:

  • an additional 4,050 care packages will be required in 2020 – an increase of 15 per cent.
  • an additional 20,101 care packages will be required in 2037 – an increase of 68 per cent.

Currently there are 16,111 care home beds in Northern Ireland, 14,948 of which are provided by the independent sector. All nursing home beds in Northern Ireland are provided by the independent sector.

Around 24,000 people receive care in their homes every week, 68 per cent of this work is undertaken by the independent sector (the equivalent of 170,000 hours.)

The services that the independent health care sector and our 30,000 staff provide form the bedrock of health care in Northern Ireland. Without them the health service would collapse as state provision would be unable to cope with demand and hospitals would be overwhelmed. So therefore, fixing the crisis in adult social care is essential not just for our sector but for the entire health service as well.

Many of the issues we face are urgent. The first is workforce shortages both for nurses and care workers.

There are significant unfilled vacancies across the social care sector, varying between 3.5 per cent and 7.5 per cent. This is likely to accelerate. The turnover rate across the UK is 28 per cent, meaning that more than a quarter of all staff leave their posts every year. This is compounded by an ageing nurse population. Half of all nurses in the health system are within 10 years of being eligible for early retirement. This creates a high dependency on agency staff and locums, which makes care more expensive to provide. Low unemployment rates coupled with low rates of pay make local recruitment very challenging.

The sector offers loving care to older and vulnerable people.


All this is compounded by Brexit. The health and social care system is heavily dependent on attracting talent from overseas. The number of non-UK Europeans working in social care across the UK rose by 40 per cent between 2010-2013. Today they account for around 7 per cent of the entire workforce. Yet nurses from other European countries are leaving the UK in droves. There was an increase of 67 per cent leaving the UK registry last year and there’s been am 89 per cent drop in new recruits from other European countries. This is exacerbated still further in Northern Ireland.

This year the UK minimum wage rose to £8.21 for workers over 25 years. In the Republic it is higher at €9.80, a difference exacerbated by a falling sterling. This makes recruitment difficult, especially in border areas.

Furthermore, UK Government policy for immigration post-Brexit is designed to attract skilled workers and prevent those unskilled from working in the UK. But the policy sets a threshold of £30,000 per annum salary, thus measuring applications on pay, not skills. This excludes care workers. They are skilled and do extremely valuable work, but their salaries average around £16,000 per annum.

Workforce shortages are already putting a considerable strain on the system. It leads to a situation whereby people who could and should be discharged from hospital are having to stay there because the care packages they need are not available. This has two effects. One is referred to as ‘bed-blocking’, meaning urgently needed beds are not available in hospitals. The second is mounting cost. Delayed discharges are costing the system £50,000 per day. This figure is likely to continue to rise unless the problem is addressed.

It is critical for social care workers to be exempted from the new immigration rules in Northern Ireland so that overseas recruitment is possible. Second the role of some care workers should be enhanced so that they can carry out some of the more routine tasks currently undertaken by nurses. Ultimately, however reasonable renumeration for workers, recognising their skills and value is the only sustainable solution.

Employers cannot currently do this because of the way that the commissioning process works. Power to People concluded that this system which is run by the Health and Social Care Trusts is not fit for purpose and produces a “race to the bottom”. This needs to be ended and reversed by establishing fair renumeration and establishing the true cost of care. Care workers are highly skilled and do extremely valuable work and that should be reflected in their pay.

As Trusts continue to grapple with tight budgets, social care has been squeezed. They have not taken account of inflation or rising costs when drawing up contracts for providers. Northern Ireland’s rural nature, and the associated higher costs in reaching and caring for individuals in their homes, have been ignored.

All this has led to spiralling staff problems with providers – low pay, a lack of investment in professional development and a high turnover of workers, as referenced above.

It should be noted that, despite Northern Ireland’s rural nature and associated higher cost, the average hourly rate in 2018 paid by our local Trusts (£13.70) is far lower than averages in England (ranges between £18.20 to £14.50), Wales (£16.78) and Scotland (£16.54).

The impact of this is making preparing for future demand extremely fraught for the independent sector. We have seen some businesses fail and others having to stop offering services in some areas. Others have withdrawn altogether from Northern Ireland. Investment in new facilities has stalled and so therefore supply is falling below demand. This in itself represents an urgent risk to the entire health and social care system.

Again, there is a solution which was outlined in the Power to People document. The current commissioning process must be scrapped. There should be a full value for money audit of all social care services that factors in the need to offer reasonable remuneration for those working in the sector.

This would ensure that the public gets a good return on its investment, whilst ensuring that those charities and businesses operating in the sector are viable and incentivised to invest for future needs. We believe that the regime that emerges from this should be controlled by a price regulator, preferably the RQIA or equivalent arms-length public body.

Finally, we need to restore dignity to vulnerable people. Currently Northern Ireland has the highest percentage
(29 per cent) of domiciliary care calls for 15 minutes or less in the UK. This does not afford service users dignity and ignores the social element of home care. Inevitably calls are therefore rushed and do not meet the needs of vulnerable people.

This uncaring and undignified practice should be discontinued with service users being allocated sufficient time to meet their needs including a guaranteed minimum of 30 minutes per call.

Addressing these issues cannot wait, there is too much at stake. The system is already collapsing and there is no time for delay.

Ihcp is the representative body in Northern Ireland for independent providers of care services for older and other vulnerable people. This includes charity, church-affiliated, private and not-for profit organisations. The services provide include both care at home (often called domiciliary care) and residential accommodation (including nursing care beds).

Pauline Shepherd

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