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Committee Inquiry into Health and Social Care Workforce Planning
Evidence from the Centre for Social Carework Research at Swansea University
This invited paper is presented by the Centre for Social Carework Research at Swansea University to the Inquiry on Health and Social Care Workforce Planning. The Centre was established in 2006 and conducts original research and reviews in the social care field. The evidence provided in the paper is based on a number of recently completed research studies and reviews in England and Wales.
2.1 Professor Peter Huxley is a qualified social worker. He was the first social worker in the UK to become head of an academic department of psychiatry (in Manchester) and the first holder of a Chair in Social Work in King’s College London. He was Director of the Social Care Workforce Research Unit (funded by the Department of Health) at King’s College, where Dr Sherrill Evans also worked. Together they came to Swansea in 2006 to continue social work and social care workforce research and to establish the Centre for Social Carework Research (CSCR). Dr. Evans worked previously at the Personal Social Services Research Unit (PSSRU) in Kent, the University of Manchester and in various local government research posts in England and Wales. Professor Huxley has worked at the interface between health and social care, as a team leader, non-executive director, and research and development lead.
2.2 A list of the recently completed projects from which the evidence in this paper is taken is given at the end of the paper for information. Dr Evans and Professor Huxley will gladly answer any specific questions that the committee may have about any of this research.
2.3 In relation to the generic questions posed in your guidance notes, we offer the following observations.
3. The division of responsibility amongst organisations charged with workforce planning and the mechanisms they use.
3.1 Workforce planning in social care has to contend with the mixed economy whereas health workforce planners do not to the same extent. Almost 80% of the social care workforce (and this figure does not include individual informal carers, or personal assistants) lies outside of the statutory services. This means that at the strategic level it is very difficult, even within social care alone, to centralise the necessary information required for workforce planning.
3.2 When we established the Centre for Social Carework Research (CSCR) we began discussions with the Care Council (CCW) and the then Social Services Inspectorate Wales (now the Care and Social Services Inspectorate Wales CSSIW), and to a lesser extent the Welsh Local Government Association (WLGA), about their separate but related responsibilities and offered to join them in an informal capacity to assist in the harmonisation of processes of social care workforce data management. To be comprehensive this arrangement would have to include the independent, voluntary and private sectors, but it is not a straightforward matter to engage one or more people who can speak for the whole of each of these sectors on workforce issues. The Care Council established Social Care in Partnership (SCIP) arrangements in four regions covering Wales to coordinate workforce development, and this does bring together people from the relevant sectors in a useful way. However the SCIPs are limited in what they can do to improve the basic workforce intelligence on which workforce planning decisions are made because they don’t have access to or control over a single definitive point of reference about the social care workforce. The CCW’s biennial report on the social care workforce is a useful summary document, but it, and anything the SCIPs wish to investigate, such as the numbers of particular workers or worker characteristics like training levels, is not available in a comprehensive form across the sector (although some data are readily available for local authorities only).
4. The availability and quality of intelligence to inform workforce planning
4.1 Within social care there are divided responsibilities for workforce data collection. Local authorities make staffing returns to the WLGA, and workforce development coordinators make returns to the CSSIW on the local authorities’ workforce development plans. In both cases individual worker level data are reported in aggregate form which is rather crude data for workforce planning purposes. Individual level data, such as that provided by a minimum data set would be much more useful for planning purposes. .Although Wales entered into discussions with England and Scotland re the national minimum data set, it decided not to go down that route. At that time of all the items collected by social services in the three countries there was only one item collected in the same format in all three returns (gender). The Care Council attempted to follow the English model of a minimum data set for social care workforce data, and we reported an evaluation of progress with the Workforce Information Template (WIT) to the Council. At that stage the WIT was too long and was not being used by most provider agencies. Further work along the lines of a minimum data set in Wales appears to be required. According to recent information there are 10,000 establishments providing data on 120,000 individual workers in the English minimum data set (representing less than one third of the estimated 39,000 providers of social care services), and there is a plan to use minimum data set information to replace the requirement to make the present social services staffing return to DH (the Welsh equivalent goes to the WLGA).
4.2 In short, social care workforce intelligence is not collected in Wales in a way that is helpful to planners. We have found that pre-inspection reports as presently constituted in England and in Wales do not provide adequate or accurate information about the workforce. This is in part because the reports were designed to gather information for a specific purpose (inspection) and data gathered for one purpose is seldom good enough to be used for a different purpose (recording workforce information). If inspection reports were to provide useful workforce information they would have to be structured differently and providers would have to be mandated to provide the information. We have worked on the National Minimum Data Set in England, when were at King’s College and on the Care Council’s workforce information template (WIT). The issues are the same - achieving a high return of good quality data from the providers in all sectors, when there is no incentive for private providers to give the information, and when some of them regard these data about their staffing levels as commercially sensitive data. It seems to us that the only solution to this data gathering problem is for an agreed set of workforce information to be made mandatory as part of the inspection process or as a required annual return.
4.3 A further stumbling block is agreeing what information is to be gathered. There is a significant issue here in relation to job titles and grades, which is not such an issue in the health service. In our work in Wales and in England we have found several hundred job titles in operation. This issue is made more problematic by the development of new and changing worker roles (see later). Without some resolution of this issue a fully operational minimum data set is a non-starter.
4.4 Another issue not faced to the same extent in the NHS is the unique identification of individual social care workers. Now that the social work profession is regulated and registered there is better information available to CCW, and there are plans to register the rest of the social care workforce as well, which will also give a better picture. The pattern of working in the social care sector, especially in the independent, voluntary and private sector is of many part time workers, some of whom have two or more jobs. There is the opportunity (as yet not realised) to use registers as sampling frames to provide answers or pointers to unanswered questions about the workforce, such as exits and re-entries and the timing of these changes. This information is extremely valuable when attempting to assess the impact of changes such as recruitment campaigns or the effects of introducing flexible working practices.
4.5 As part of our service level agreement with the Care Council we are expecting to assist in the study of cohorts of social work graduates from all programmes in Wales over the coming years. This will provide the required information about recruitment of graduates into the workforce, any exits from the workforce and the reasons for this. This will provide data on the benefits of the investment in social work education and training. The findings will be compared to similar research undertaken at the Social Care Workforce Research Unit, at King’s College London and the Sharpe Consulting research which is part of the DH England’s Policy Research Programme’s recently established workforce research programme.
4.6 We feel that to attempt an overarching centralised workforce planning system involving health and social care can only realistically be achieved by getting the social care sector up to speed first. Otherwise there is a risk that the planning will be entirely health related because social care lacks the same amount or quality of workforce information. In arranging to enhance the capacity of the sector to provide better quality information it would, however, be helpful and necessary to have input from the health and education sectors, where there are a number of work roles that have a degree of commonality with social care workers, such as support workers. Whatever data are gathered an important principle is that individuals should only be asked to report them in response to one coordinated request rather than multiple duplicate requests, and that they should be given the confidence that data are being appropriately used, through appropriate feedback mechanisms.
5. Changing patterns of demand and service provision
5.1 The changing demography of Wales is well established, as is the general assumption of the desire of the ageing population to remain in their own homes for as long as is practicable. As part of the study of Ten High Impact Changes in England we investigated the current state of knowledge about Telecare (the provision of information technology to monitor and support the older person to live in their own specially adapted home) which was widely held to be an important tool in meeting the anticipated demands of this population. We reviewed six papers, two from one project in Stirling, and one of six reported by the Imperial College team (because it was the only one with any impact data in), and three others. The general conclusion is that the probable advantages of Telecare may have been overestimated, and the obstacles to implementation underestimated. Users did value some of the impacts and benefited from reduced anxieties e.g. regarding falls. Overall the evidence is mixed, and its use seems to be more successful in health care than it is in social care. There are anxieties about its use for surveillance purposes and the possible adverse consequence of reducing social contacts, but there was no evidence about these as actual problems at present. Telecare probably will have an important role in the future but the evidence to date is not yet robust.
5.2 Patterns of demand for services need to be established independently of providers. If the health and social care providers are allowed to specify demand with little or no reference to the needs and wishes of the people to be served, then they can determine the demand to be for 'more of the same’. To illustrate some of the problems here we refer to our ongoing study of the determination of the health and social care composition of community mental health teams. In the past, when these teams were created very little thought went into their composition. At least one respected author has suggested that the need for a multidisciplinary team was based on the clinical judgement of psychiatrists. As a result present team composition can be a result of historical precedence, or of resource limitations, rather than formal workforce planning. In some cases, an estimate of the population morbidity (in clinical terms) is used to determine the need for some professional groups but there is rarely any consideration of the best balance between health and social care professionals, or support workers. More recently, in some services the decision about team composition is being determined by a skills and competency judgement. That is, 'what skills do we need in the team?’ rather than 'what type of worker do we need?’ Where the team skills approach is used, if uninformed by service users or social care staff, we suspect that the skills that emerge as 'required’ are largely those held by health care staff. Hence the teams are developed with little or no social care staff in them, and yet they are seen to be meeting demand with the skills 'deemed to be required’ within the service.
6. Joint working between health and social care agencies
6.1 In the 10 High Impact Changes study we reviewed the literature on the impact of joint working. There is a wealth of literature in this area and seventeen studies were reviewed. Only a small number of studies present research findings about the impact of integration and many, if not most, of these present negative results. That is, the anticipated benefits of various integration arrangements fail to materialise; there seems to be a tendency to overestimate the advantages before the study begins. Some studies report higher stress levels among staff working in integrated teams, in other studies the actual level of practice integration or shared values and procedures is extremely limited. Similar negative findings are reported in relation to service reorganisation and local authority changes. In most studies integrated services fail to show better results than standard service comparison groups, but there is a lot of variability in both the forms of integration and the nature of the comparison group. One study found that integration impacted more on management than it did on front line practitioners. Two studies (one by Huxley and Evans et al) found that social workers were better able to make social assessments in integrated services than other professional staff.
6.2 In the focus groups that were part of the 10 High Impact Changes study, there was 'a degree of hilarity’ about integration of health and social care services (this was in England) and comments such as 'the right hand doesn’t know what the left hand is doing’ and 'on the ground it is not happening for people’ which rather supports the negative findings in the research literature. So does the fact that several different professionals can still turn up at the user’s home at the same time (which the Seebohm tried to resolve in the 1960’s and 1970’s). There was a range of experience, reflecting the research evidence, from good experiences of joint working to those who found it was impossible to arrange. There were similar issues for the manager’s focus group: 'we’re supposed to have integrated care teams but health pulled out’. While managers thought that joint working was in principle better for service users, it was hard to achieve when 'health and social care are culturally, professionally, technically, managerially different.’ Some managers thought teams were integrated 'in name only’ and another thought nurses we 'too risk averse’ and this affected team functioning. Carers pointed to a serious lack of communication between agencies and professionals. Practitioners had some very positive and others some very negative teamwork experiences depending on which health provider they related to.
6.3 The unified or single assessment process is intended to help to integrate health and social care assessments and care planning. The evidence we reviewed about the single assessment process is mixed at best. There is some expectation that the SAP might enable future hospital admissions to be predicted, but on the other hand some reports that services oriented towards an outcome focus find the SAP an obstacle to this approach. According to the managers’ focus group, professional preciousness and health and social care territorial disputes have spoiled the implementation of a basically good idea. In some places in England the health service refuses to operate it. Carers believed that the framework was in place but operated slowly, and that social workers suffered from all the other changes being brought in at the same time. Practitioners found the process bureaucratic and lengthy but also difficult to implement because of the resistance of the health service to its use.
7. To what extent is workforce planning anticipating changing patterns of service commissioning and provision and the changing or blurring of professional roles?
7.1 Recent developments in commissioning of services mean that it is very likely that more commissioning will be undertaken by individuals. A recent report by the ADASS in England has highlighted these potential changes, and the workforce implications. They say:
"with the extension of choice, direct payments and individual budgets putting people more in control, much of the future workforce may be directly employed by individuals. Social care is about creating opportunities to enable/assist service users and carers to make their own life choices. However it is not possible to consider planning the social care workforce in isolation. There needs to be an integrated workforce plan across the whole system to have a workforce that delivers according to peoples needs and not according to organisational outcomes”
"The workforce agenda that stems from this vision is substantial - new skills mixes, new roles, new joint teams, new employers and self-directed services through Individual Budgets in which individual employees (disconnected from employer organisations) may be a growing proportion of the workforce. In any event most of the workforce will be in the independent sector with significant recruitment, retention and qualification problems.” (ADASS/CSIP 2007)
7.2 As part of the review of high impact social care changes, we reviewed the existing evidence about the impact of one of these new arrangements, the provision of Direct Payments (DPs). Five out of the six papers reviewed focus on the implementation of DPs schemes, and the role of personal assistants, rather than on outcomes or impact. This relative lack of evidence is in part due to the slow or non-existent take up of DPs by some service user groups. The only study that looked at the final outcome, that is the impact on service users themselves, was a best value review rather than research and it was conducted in the absence of direct comparison group receiving other forms of assistance. There is no doubt that, on the basis of the findings of qualitative studies, that DPs are welcomed, and enhance choice and control and are said to enhance quality of life. They can also present interpersonal and responsibility burdens that some service users find problematic. The wider impact on services, staffing and the workforce in general have not yet been addressed by research.
7.3 Users and carers both reported some of these anxieties ('I’m not using them because I cannot face it. Neither my husband not I could face the stress of it’; 'I use an agency, the idea of being an employer is scary to me’; 'I have had to write a 35 page health and safety policy’) and there was a range of experience from very positive to never having heard of them. Managers reported that is was a time-consuming process which was a problem if the care needs were urgent and practitioners identified a number of problems, some of which could be ascribed to teething problems. Although people speak highly of DPs there are vast differences in the quality of schemes and the consistency between them.
8. Does workforce planning take sufficient account of the need for trained and effective managers?
8.1 Probably not; for us the key question here is what should be in the training and who should provide it. Some of the NHS leadership programmes have little content or bearing on social care issues. Some people argue that the management training required in the private sector is more like that required to run a small or large business.
8.2 In order to develop evidence based work in social care, practitioners need to have access to the sort of training provided in the NHS in relation to critical appraisal skills, that is the ability to read the published evidence and be able to critically look at the way it was conducted so one can know whether it can be relied upon or not. There is a distinct tendency in social care and social work for the results to be accepted uncritically. Managers need to understand this, both for themselves but also so the staff can be provided with the same level of skill in this as their health colleagues. Specific programmes need to be provided for different staff groups.
9. To what extent have the European Working Time Directive and the increasingly international labour market had an impact on, and been acknowledged in, workforce planning?
9.1 There is an intelligence gap around the internationally recruited workforce. We have undertaken three pieces of work on this issue, the last one in Wales for the CCW, and we found that it is very difficult to get an accurate picture of the number of internationally recruited workers, again, partly because there is no single way to obtain this in the same format from all employers in all the sectors. We had a 100% response from the Local Authorities in Wales, but a very limited response from the private sector, partly as we indicated earlier because of commercial and other sensitivities in this area.
9.2 We have proposed another study to WORD to attempt to address this issue, and to interview recruits and their fellow team members, something which has not been done systematically to date. There is anecdotal evidence that international recruits in social work are generally very well trained and bring a lot of positive benefits to practice, but there are also anecdotal stories about some high risk practices being undertaken because of cultural differences, e.g. in child care practice (not in Wales).
10. Summary / Recommendations
10.1 There are one or two other points that have not been raised above, and the main one of these is the need for better information about how the social care workforce impacts on the quality of social care provided by services and the impact on the quality of life of the recipients of services.
"Councils are required to plan, but individuals need to be allowed to make choices about the support that they require or need. The workforce plan should consider how all employers, including individuals, can employ a workforce that delivers high quality services that achieve the outcomes service users and their carers choose.” (ADASS/CSIP 2007)
10.2 There is a need for the generation of better quality information, and better coordination of information about the social care workforce across all the sectors, but there is also the need for more and better quality research evidence for planners to base their decisions on. The research agenda and the information agenda need to be linked. Research needs to take place where the evidence base is weak, and registration and other routinely gathered workforce data needs to be subject to more sophisticated analysis to reveal trends over time, and the impact of initiatives such as flexible working and new roles.
11. Centre for Social Carework Research - projects informing this paper (11.1 to 11.5) and relevant planned projects (11.6- 11.9)
11.1 Training, quality of care and outcomes in residential homes for older people
Conducted for Social Services Inspectorate Wales. Involved literature review, review of web-based resources and analysis of a sample of inspection reports. Report submitted March 2007. Four page summary currently being produced for publication and dissemination by CSSIW in English and Welsh.
11.2 International Recruitment in Social Care in Wales
Conducted for Care Council for Wales, with whom we have a Service Level Agreement to conduct research. Report on Phase 1 submitted in March. This focused on reviews of evidence from literature and web-based resources and a short telephone survey of all HR managers in SSDs to identify the nature and extent of international recruitment within departments. Phase 2 involved a sample of provider agencies, and Phase 3 was a survey of local authority training officers. The final report was submitted in August 2007.
11.3 National survey of the composition of community mental health teams across England and Wales
This study is underway. The first phase involves asking five questions of mental health service leads (or other key personnel) to identify how CMHTs are composed, how that composition was determined and the implications of that composition for service delivery and performance. Subsequent phases will involve a sub-set of teams with different compositions, for which the organisational culture and climate of the team, the job content of staff and outcomes for service users will be examined. (Funded by the Department of Health in England).
11.4 Ten High Impact Changes in social care
We were awarded a grant from the Care Services Improvement Partnership in May, to conduct a scoping review of 10 High Impact Changes in Social Care. This involves a review of evidence from literature and web-based resources, and focus groups of service users, carers, social care practitioners and managers, and service planner and comissioners, who will be asked to endorse the findings of the review, and prioritise these changes in terms of their impact. The 10 High Impact Changes will then be costed by a health economist. Final report was submitted in August 2007.
11.5 Skills audit of foster carers in Wales
Funded by Care and Social Services Inspection Wales (CSSIW) via CCW but not as part of the SLA, this will involve a review of literature, web resources and secondary analysis of any existing data to determine what the skills and experience of foster carers are, and whether they differ by foster carer type. Final report delivered in September 2007.
11.6 Review of research capacity and priorities for social care in Wales
In collaboration with the Older People and Ageing Network (OPAN), CSCR have recently been commissioned (July 2007) by the Wales Office for Research & Development (WORD) to undertake a review of research capacity and priorities for social care in Wales, and to examine ways of developing outcomes driven services. This work will involve face-to-face, group interviews with key representatives of social care services, providers, users and carers in the first instance. This will be followed by a prioritising exercise, to be conducted more widely, and electronically. This work will commence in September 2007 for 12 months.
11.7 Organisational climate and culture of Older People’s teams
CSCR have recently been awarded a new grant from the Department of Health in England, to conduct a study of the organisational climate and culture of Older People’s teams that complements the study of CMHTs. This study, which will start in July, uses the same methods and measures as the study of CMHTs, and is being conducted in collaboration with colleagues in Glasgow and Sheffield, so it will provide useful comparisons with workforce issues in Scotland and England.
11.8 OPAN bid for a Social Care Outcomes Research Development group
Dr Sherrill Evans recently submitted a bid to OPAN, with Chris Baker, Sally Philpin, PH and Heather Tyrell from Blaenau Gwent Social Services, to establish a research development group. This group will be tasked with identifying and prioritising the top three social care outcomes related research questions, and then drafting three research proposals for funding from appropriate funding bodies. This work will inform the planned development of a social care outcome network, for which funding will be sought from WORD, ESRC or another appropriate body.
11.9 WORD bids
We recently submitted seven bids relating to social care and its workforce. All have been successful in progressing to the second phase (ie full-proposal stage). These bids relate to:
International recruitment - the views of recruits, co-workers & service users
Worklife balance - building on the work of 'Profession to value’
NVQ assessors - why don’t trained NVQ assessors and verifiers practice
10 High Impact Changes in social care in Wales
Outcomes in social care
Organisational climate and culture of Older People’s teams - two case studies
The relationship between staff training and quality of care and quality of life in residential care homes - a pilot study.