76.Health and Social Care have been structurally integrated in Northern Ireland since 1973, which makes it distinct from health systems in England, Scotland and Wales. The integration of health and social care is now widely seen as a desirable model among policy makers as the health and social needs of communities are often inter-related and integration allows for better coordination and continuity of services.
77.Social services encompass a range of personal care and practical assistance for children, young people and adults who require extra support. It includes support for the elderly, support for those with learning and physical disabilities, support for people with mental health needs, the homeless, people with substance abuse problems, victims of domestic abuse, child protection and end-of-life care. ‘Social work,’ which is a qualified and registered profession operating within legal frameworks to protect and support vulnerable people, is distinct from what is commonly referred to as social ‘care’ work, which does not generally require a formal qualification and deals with more direct, personal care to support vulnerable individuals with daily tasks and to engage with their community.
78.A significant amount of social care is provided by the private and voluntary sectors. According to the Department’s workforce strategy, there are approximately 31,000 registered social carers in Northern Ireland, including 12,000 domiciliary care workers. It estimated that 75 per cent of these were employed in the independent sector, with 25 per cent employed by HSC Trusts. A recent survey found that, out of 870 sites providing over 1,000 adult social care services, 51 per cent were privately run with a further 24 per cent run by voluntary providers.
79.The Bengoa report called for greater “depth” in the integration of health and social care in Northern Ireland, stating that “the benefits of integration have not been fully exploited” and that this would “require a great deal more work on how the system plans, funds and purchases care across acute care, general practice and community health, and social care provided by statutory, independent and community, voluntary and charitable providers.” Bengoa envisaged a central role for social care in a transformed health service, highlighting its importance in preventing people from being admitted to hospital and subsequently facilitating their discharge when medically fit. The report further acknowledged that securing investment in social services had been difficult when faced with competing demands for healthcare investment but that there was a strong economic case for meeting social needs as unmet needs were associated with higher rates of emergency care, hospital admissions and readmissions, along with being linked to a number of costly health conditions including heart disease, mental disorders, diabetes and hypertension.
80.The recent review of adult social care highlighted the broad and dynamic reach of social care, with overlaps in housing, education, work, leisure, transport and criminal justice services, stating that “it is vital that adult social care is acknowledged to be multifaceted, subject to and benefitting from multidisciplinary partnerships and relationships.” It further emphasised the value of social care, stating that “social care should be recognised as a vital and positive part of the infrastructure of society and the economy.”
81.Tasked with identifying key areas for reform in adult social care, an expert panel was established in December 2016 as part of the Department’s Reform of Adult Care and Support project. The panel’s report was published in December 2017 as Power to People (2017). Among its findings was that although “care work is highly skilled” care workers “receive amongst the lowest wages in the labour market, typically the minimum wage.” In addition:
In the public sector, wages (and conditions) for care work are fairer, whilst in the private and voluntary sector, pay is often at minimum wage rates and service conditions have been eroded. Given that the majority of paid care work is now provided in the private and voluntary sector, there is clearly an imbalance. It also makes the divide between social care (largely provided by the independent sector) and health care (largely provided in the public sector) uneven in ways which can undermine career development and stability. It also hinders attempts at effective integration as the gulf in perceived value is so stark.
The outsourcing of care to the independent sector had led, according to the panel, to competition between providers based “almost exclusively on price” and consequently a “race to the bottom” as “by far the largest cost for any care provider is the cost of staff.”
82.The Health and Social Care workforce strategy, published in May 2018, shared these findings. According to the strategy, social care services were “reliant on the independent sector for the delivery of effective and efficient social care.” The report noted that:
There can be considerable differences between the terms and conditions of employment for social care workers in statutory organisations and those employed within the independent sector. Lower pay, less favourable conditions, temporary or zero hours contracts and a perceived lack of recognition of their value to society, have all contributed to low morale and a high turnover of the workforce.
It further stated that “investment in learning and improvement for social care workers tends to be more limited in the independent sector.”
83.The Royal College of Nursing told us that “the relationship between the HSC and the independent sector (and particularly the financial dimension to it) is in urgent need of re-examination and reappraisal,” claiming that the independent sector was unable to compete with the HSC in the supply of appropriately skilled and experienced staff. Age NI told us that it was “vital” that the role of community and voluntary organisations was recognised and that services should be provided by “a skilled, competent and valued workforce, with decent salaries, stable working conditions and manageable workloads,” along with opportunities for continuous learning and improvement.
84.The difficulties in recruiting and retaining social care workers were further explored in the Northern Ireland Social Care Council’s workforce review Social Care Matters (2017). The review noted that a major challenge in responding to instability in the workforce was the lack of comprehensive data on social care which impeded workforce planning at a system-wide level. The NISCC argued that it was “important to invest in a regionally agreed and maintained set of workforce and sector data which will properly inform future social care workforce strategy and policy.” The review agreed that due to competition with other low wage sectors social care needed to “demonstrate that it is an attractive and worthwhile career choice” but was currently falling short in its offer of poor wages, terms and conditions of employment and recognised career pathways to potential employees. It recommended continued development of a competent social care workforce through core training, continuous professional development and opportunities for training and qualification which would open up career pathways to higher level roles within social care.
85.The Cedar Foundation, a charity supporting people living with disability, autism and brain injury, told us that “the competitive pressures with other sectors of the economy, principally retail and hospitality, is presenting unsustainable pressures on the recruitment and retention of this workforce.” They added that “all providers are now increasingly having to access short-term agency staff which is placing additional cost pressures upon the system, potentially undermining the quality of care that is being delivered.” The Cedar Foundation also highlighted the problem of high levels of turnaround or ‘churn’ within the workforce, whereby workers move between employers or within organisations taking their skills and experience with them. This has meant that “there are fewer new entrants into the workforce” and that “internal movement is driven by nominal differences in pay rates. In effect the workforce quantum remains the same, costs increase for the new employer to achieve marginal gain [and] the previous employer faces voids and increased costs due to agency use to cover care commitments.”
86.Marie Curie, a charity which provides care and support to people with terminal illnesses, told us that care providers had been unable to secure the staff needed to fulfil domiciliary care packages, contributing to delayed hospital discharge for patients across the health service. They said that “challenges in attracting and retaining staff, owing largely to low pay, lack of professional status, poor conditions and inadequate opportunities for career development and progression” had created “a destabilising churn and shortage in the workforce, with providers unable to secure the staff needed to fulfil packages of care.”
87.The Committee heard from a number of independent providers and others that the disparity in conditions and wages between the independent and statutory sectors was having a negative impact on the provider network. The Cedar Foundation criticised the role of the Health and Social Care Trusts in making “superior and inequitable” offerings which, due to the dual role of Trusts in both the commissioning and provision of services were “in effect distorting the social care employment market while failing to support the provider network.” These criticisms were shared by the Compass Advocacy Network (CAN), a charity which offers training opportunities for adults with learning disabilities, autism and mental health issues, who told us that:
Evidence has proven [ … ] that voluntary and private organisations provide a more cost-effective social care service and 74 per cent of social care registered providers fall within these sectors. Yet salaries, terms and conditions offered by the statutory sector, or outside of social care, make employment within a Trust, or in other sectors, a more appealable option. Voluntary and private organisations are investing in the professional development of the workforce, only to risk losing them to a Trust. Not only is this costly and frustrating for the private and voluntary sector, but further impacts negatively on the sector collaborating to address the workforce pipeline challenge.
88.Inspire also told us about losing staff to the Trusts after having invested in professional development:
We have young people who come to us as their first career. They will be recruited by us, go through training, get maybe a couple of years experience and then almost invariably go into the local health trust for a job because they are better paid and have better pensions. We have done all the training. We have given them the experience, but it is really hard for us to hold on to them because we cannot match what the trust does.
89.Some of the difficulties faced by independent providers when competing with the statutory sector were outlined by CAN. They pointed to the regulatory burden on independent social care providers and the financial pressure this has put them under, including areas such as safeguarding, health and safety and GDPR, citing substantial investment in “resource, technology and management information systems to cope with this increased regulation.” According to CAN, independent providers had come under increased financial pressure through budget freezes representing an equivalent real terms cut in excess of 20 per cent; the introduction of pension auto-enrolment which was not accounted for when budgets were originally set; and the introduction of the National Living Wage in April 2016 which accounted for the single largest overhead—at over 80 per cent of overall budgets. The consequence of annual uplifts in the National Living Wage had led, according to CAN, to an inability to provide uplifts for staff in more responsible positions. CAN ultimately argued that “what are deemed statutory services tend to be subsidised by us, as a voluntary provider.”
90.The independent social care sector is struggling with competition from the low wage sector, particularly hospitality and retail, and a competitive relationship with the statutory sector. High quality social care requires a skilled and valued workforce but social care workers are often on low wages and have little scope for career development and progression. Action must be taken to make social care an attractive career choice and create closer parity between the independent and statutory sectors. The Committee recommends that the Department conduct a review of social care roles across the board to identify inconsistencies in roles, responsibilities and salaries as a step towards consolidation of the social care workforce. This review should be completed by summer 2020. The Department should further set out what steps are being taken to progress the proposals set out in Power to People for equalising pay and conditions across the social care workforce in response to this report.
91.In common with other areas of healthcare, social care has been impacted negatively by short-term budgets. The Northern Ireland Council for Voluntary Action told us that this had impacted particularly on the community and voluntary sectors, with year-on-year uncertainty impeding organisations’ ability to retain staff and sustain services. Age NI told the Committee that community and voluntary providers were at the forefront of prevention and early prevention and that it was vital that effective planning was in place to maintain funding for these providers or to identify alternative service options should funding come to an end.
92.Marie Curie told us that “short-term budgets propped up by non-recurrent, in-year funding is not working” and remarked that a short-sighted approach to budgeting had led to counter-strategic decisions, giving the example of in-year savings measures in 2017 leading to cuts that were ultimately reversed:
Funding shortages meant local health trusts had to consult on in-year saving measures. Many of the proposals put forward, including cuts to domiciliary care, Self Directed Support and nursing home places, were entirely counter-strategic and were reversed after significant public pressure. We would be concerned about this process being repeated—the saving plans did nothing to resolve the long-term and strategic problems facing the health service and only succeeded in causing unnecessary anxiety among patients and service providers, as well as damaging public trust in health decision-makers.
93.Marie Curie also linked the problem of delayed hospital discharge to a lack of long-term strategic planning. Data secured from Freedom of Information requests by Marie Curie showed that in 2017–18 there were 46,148 delayed bed days across the health service due to delayed discharge, averaging at more than 3,800 delayed days a month, mainly due to a lack of domiciliary care packages and a shortage of available care home beds. 204 patients died while waiting to be discharged from hospital during 2017–18. Marie Curie claimed that in the face of rising demand and budgetary shortfalls, existing structures could not cope and that, along with investment in the workforce, a range of funding measures for social care should be looked into with “a move away from short-term financial planning, in favour of longer-term budget setting, so that services can be commissioned and planned in a more strategic way.”
94.We also heard that short-term contracts were a problem for many providers. Barnardo’s Northern Ireland told us that short-term contracts restricted innovation and learning, given that a proportion of this period was spent on ‘bedding in’ at the beginning and preparing to re-tender at the end. Barnardo’s Northern Ireland advocated long-term partnerships of at least five years in place of short-term contracts to deliver a range of improved outcomes:
With longer contracts, voluntary organisations like Barnardo’s can provide meaningful support and effective interventions, whilst also developing sustainability of the service. This sustainability allows innovation and learning, as well as strategic planning to promote better outcomes. We recommend that short-term contracts are replaced with a longer-term strategic partnerships model, in line with an outcomes-focused rather than task orientated approach to commissioning and strategic investment.
95.Action for Children similarly told us that “like other sectors, the voluntary and community sector needs to be able to plan ahead and often leads the way in finding innovative solutions, based on collaborative working” but that this required “more sustainable contract periods.”
96.Short-term budgets are having a particularly negative impact on social care, with year-on-year uncertainty impeding the ability of providers to plan for the future and develop service innovations. As we have recommended in paragraph 36, three-year minimum budget allocations are needed for the Department of Health. This should facilitate the Department moving towards a minimum five-year partnership model with community and voluntary providers in which commissioning and investment are based on progress towards agreed outcomes.
97.The Committee heard that excessive bureaucracy was having a significant impact on social workers. The National Director of the British Association of Social Workers Northern Ireland told the Committee: “I cannot stress enough to this Committee the importance of the issue of bureaucracy to social workers” and that “any time we engage with social workers, the single biggest issue they talk to us about is bureaucracy and paperwork.”
98.A 2012 survey conducted by the Northern Ireland Association of Social Workers found that, of those surveyed:
99.In the same year the Department of Health, Social Services and Public Safety launched its 10-year strategy for social work in Northern Ireland—Improving and Safeguarding Social Wellbeing. Among its strategic priorities were to “improve employer supports for social workers in carrying out their work” which would require “employers to ensure social work time and skills are used to best effect” and a reduction in “unnecessary bureaucracy for social workers [ … ] ensuring a healthy working environment with appropriate administrative and technological supports.”
100.A report published in 2018 on progress made against the 2012 strategy found that “while there have been a number of successful small-scale initiatives to address [social workers’ time in direct practice], their impact on the wider system has been limited.” We were told that, with respect to the strategy, “while there was great intent [ … ] and a lot of effort, unfortunately, there has been a minimal impact, in terms of how much bureaucracy has been taken out of the system.”
101.The Committee heard that excessive time spent on paperwork represented a waste of social workers’ skills and expertise. The British Association of Social Workers put it to us that:
You have a social worker who is highly skilled, has gone through university, is skilled, trained and ready to do a job working with people. To expect them to spend 70 per cent of their working day and week filling out paper forms, duplicating those forms by putting them on to a computer system and inputting data is just unacceptable. We would not accept that of other professional jobs. We would not accept, for example, our GPs spending 70 per cent of their clinic time filling in a form. We should not accept it in social work.
102.We heard of a number of negative impacts on service users of excessive bureaucracy. We were told that it curtailed the opportunity for social workers to build productive relationships with service users and that the number one priority of service users was the availability of their social worker. The inability of social workers to visit, or of service users to get hold of their social worker on the phone, was a source of stress for many. We were also warned that “you often hear the mantra, ‘If it’s not recorded, it didn’t happen’” and that “there has been a sense of covering oneself that has grown up [ … ] that has become an embedded culture now.” The British Association of Social Workers told us that:
The response to practically every single inquiry where there has been a death or serious injury of a child, over the last two or three decades, has resulted in increased bureaucracy, so increased forms. There is a notion that having a piece of paper, having someone fill in a form and tick a box, or do an increasingly lengthy assessment, is the solution to that and we say it is not.
103.Despite these concerns, it was made clear to the Committee that good-quality recording and report writing were integral to good social work practice and that clear records were essential for governance and accountability. However, the quantity and in some cases duplication of documentation was described to us as excessive and wasteful. The British Association of Social Workers gave the following description of the bureaucratic processes surrounding looked-after children:
There are huge amounts of paperwork that start when a child becomes looked after, and rightly so. There should be good processes around documentation, but the documentation is excessive. Each child in a family, if there are six or 10 children, has to have this set of documents, 50-plus pages of documents, which are required at different points of time for review processes. Child protection processes often run at the same time. There is different documentation for the child protection process, and there is a UNOCINI [Understanding the Needs of Children in Northern Ireland assessment framework], which is a single assessment for children’s services. All this different documentation runs at the same time. This is our question: why are there three different requirements for forms that all relate to the one child and assessing their needs? As a real example of that, for children who have a disability, if they require one night’s respite care in a year, they automatically become looked-after children. That gives them a certain legal status. They are then required to become subject to the full looked-after process, so all the forms I am talking about have to be completed for that one child, for one night. It is unacceptable.
104.We were sent the forms associated with the assessment of need in adult social work services from a social worker employed in the Northern Health and Social Care Trust. The core Northern Ireland Single Assessment Tool (NISAT) ran to almost thirty pages and was associated with a further eleven forms involved in the assessment and support process. We were told that this did not include further paperwork associated with additional stages and that this was in addition to the requirement of social workers to keep a contemporaneous running record of phone calls, emails, letters and visits and carry out a review of care every six months. The Committee heard that although the idea behind it was for all professionals involved in a person’s care to provide input, in reality social workers were having to capture all the information as other professionals saw it as a social work task.
105.Social workers are spending too much time filling in paperwork and this does not represent the best use of their skills or expertise. Despite recent efforts at reducing the bureaucratic burden on social workers this continues to be a problem and is negatively impacting on both the profession and the people who depend on it. The solution to this problem should not itself be overly bureaucratic and meaningful change could be brought about quickly and inexpensively. The Committee recommend that a task force be established with the remit and the authority to remove unnecessary and duplicated paperwork and streamline existing paperwork—though this should not be at the expense of high-quality assessments or casework. This should be completed by summer 2020. In the medium-term the Department should implement IT solutions and increase the number of administrative staff available for supporting social workers.
181 Skills for Care and Development, , 5 June 2018, page 5
182 , 25 October 2016, pp. 45–46
183 Ibid., page 20
184 Ibid., page 46
185 , 11 December 2017, page 17
186 Ibid., page 17
187 Ibid., page 53
188 Ibid., page 54
189 Ibid., page 54
190 , May 2018, page 9
191 Ibid., page 48
192 Ibid., page 48
193 Royal College of Nursing ()
195 Age NI ()
196 Northern Ireland Social Care Council, , October 2017, page 21
197 Ibid., page 21
198 Ibid., page 22
199 The Cedar Foundation ()
201 Marie Curie ()
204 Compass Advocacy Network ()
205 Compass Advocacy Network ()
208 Northern Ireland Council for Voluntary Action ()
209 Age NI ()
210 Marie Curie ()
211 Marie Curie Northern Ireland ()
212 Marie Curie ()
215 Barnardo’s Northern Ireland ()
216 Action for Children ()
219 Northern Ireland Association of Social Workers, , November 2012, pp. 6–9
220 Department of Health, , April 2012, pp. 13–14
221 Department of Health, , December 2018, page 24
Published: 2 November 2019