Homecare plays a vital role in enabling us all to live well at home and flourish in our communities, regardless of age or ability.
A new report from the Homecare Association details the findings of enquiries, made under Freedom of Information legislation, to 340 public organisations which purchase homecare across the United Kingdom. These consisted of local authorities, Health and Social Care (HSC) Trusts in Northern Ireland, Clinical Commissioning Groups (CCGs) in England, Local Health Boards in Wales and regional NHS Boards in Scotland. Of the public organisations contacted who replied, 312 confirmed that they purchased homecare services from the independent and voluntary sector and provided data, making this the most comprehensive and up-to-date analysis of its kind ever conducted.
Responses showed that, since 2020, the number of hours of homecare purchased by public sector organisations has risen by 11% in the United Kingdom overall - 16% in Wales, 12% in Scotland, 11% in Northern Ireland and 10% in England.
Average hourly fee rates for homecare, weighted for the volume of hours purchased, by both councils and health organisations combined, were as follows: £18.66 (England, £18.54 – councils; £19.54 – CCGs); £19.30 (Wales, £19.33 – councils; £19.06 – Local Health Boards); £18.62 (Scotland); and £15.76 (Northern Ireland).
Only 1 in 8 (13%) of public organisations that provided figures were paying an average price at, or above, the Homecare Association’s Minimum Price for Homecare of £21.43 per hour, which we calculate as an absolute minimum to ensure compliance with the national legal minimum wage of £8.91 per hour, care regulations, and to enable sustainability of services. Indeed, in Scotland and Northern Ireland, this percentage drops to 3% and 0% respectively.
Only 28% of public organisations have undertaken a recent calculation demonstrating a rationale for the fee rates paid for homecare.
Shockingly, four public organisations reported paying average fee rates below £15.19 per hour, which is the direct cost of a careworker on the national legal minimum wage of £8.91 per hour, plus average employment on-costs (pension, NI, holiday and sick pay, travel and mileage). The problem with this is that it leaves nothing to cover the other operating costs, and thus risks non-compliance with employment and care regulations, poor experience for those receiving and giving care, and provider insolvency.
• Halton (£12.68)
• Western HSC Trust, Northern Ireland (£14.21)
• Ealing (£15.00)
• Basildon and Brentwood CCG (£15.11)
In total, 23 public organisations reported paying less than an average of £16 per hour for homecare, including four out of five Trusts in Northern Ireland. This risks careworkers not receiving the national legal minimum wage for all hours worked, including travel time, and the ability of homecare agencies to deliver good quality care.
Areas with the highest levels of deprivation recorded the lowest average fee rates for homecare. This increases the risk that poorer areas of the UK receive poorer quality of care, or experience higher levels of unmet need, exacerbating inequalities.
Low fee rates for homecare are a direct consequence of inadequate central government funding of councils for social care. In turn, this leads to poor pay, terms and conditions for the workforce.
At a time of rising demand for homecare, more careworkers than ever are leaving and employers are reporting a 75% reduction in applications for jobs. Poor pay, terms and conditions of employment are a key factor. On top of this, the COVID-19 pandemic has left careworkers exhausted and disillusioned. Careworkers rightly feel undervalued compared with equivalent roles in the NHS, and with those requiring less skill and training in retail and hospitality.
Councils report being deluged with requests for help from older and disabled people in the community, which they are unable to address, and NHS trusts are struggling to discharge people from hospital due to lack of capacity in social care and community services. This makes it difficult to reduce waiting lists as swiftly as required, regardless of how much extra funding is poured into the NHS.
To date, government has announced funding of £500 million over three years from 2023 for training and well-being of the workforce of 1.5 million. Whilst welcome, this is only £111 per person per year. A workforce capacity grant of a further £162.5 million was announced on 21 October 2021, which equates to £100 per member of the care workforce. Whilst this is helpful in the short-term, it is hard to see how this amount will enable professionalisation of the care workforce, as claimed by the government, nor address long-standing issues with poor pay, terms and conditions of employment.
Care roles are far more than minimum wage jobs and we need to go further to attract, retain and develop a talent pool for the future.
Providers in many areas are reporting that the national legal minimum wage of £8.91 per hour is insufficient to attract and retain skilled careworkers and a wage equivalent to NHS Band 3 healthcare assistants with 2+ years' experience, £11.14 per hour, is required.
Based on the Homecare Association’s costing model, a fee rate of £26.31 per hour would be required to pay careworkers £11.14 per hour plus cover the other operating costs, most of which are related to meeting care regulatory requirements. These include management, supervision, training, recruitment, IT, telephony, PPE and supplies, regulatory fees, insurance, rent, rates, utilities, governance, legal and HR fees, business administration and a surplus for investment.
The Homecare Association calls on central government to invest properly in homecare, so we can address unmet need, reduce inequalities, extend healthy life expectancy of older and disabled people and reduce pressure on the NHS.
We recommend that in the short-term:
1. Additional funding is made available urgently to enable careworkers to receive wages equivalent to Band 3 healthcare assistants in the NHS with 2+ years’ experience (£21,777 p.a., or £11.14 per hour). We calculate that this will require an additional £1.72 billion per year overall across the United Kingdom, split as follows:
• £1.30 billion per year for England;
• £75.3 million per year for Wales;
• £238.4 million per year for Scotland;
• £111.9 million per year for Northern Ireland.
2. Local authorities and health bodies are funded and required to pay a fair price for care, using a rational methodology, which enables careworkers to receive a minimum of £11.14 per hour, and homecare services to be of good quality and financially sustainable. Using the Homecare Association costing model, we calculate this to be £26.31 per hour.
3. Purchasing homecare by the minute is outlawed and replaced by payment in advance on planned homecare. This will help to stabilise and develop homecare provision by: a) providing greater security of income; b) encouraging investment in workforce and technology; and c) reducing the risk of provider insolvency.
4. Current national needs and regional variation in demography and workforce are recognised and social careworkers are added to the Shortage Occupation List.
We recommend that in the longer-term:
1. An expert-led workforce strategy for social care and a ten-year workforce plan are developed, aligned with the NHS People Plan in the United Kingdom.
2. A professional register for careworkers in England is created, in line with Scotland, Wales and Northern Ireland, which is adequately funded and carefully implemented.
Homecare Association CEO, Dr Jane Townson said:
“Once again, the continued deficit in funding for homecare services for older people across the United Kingdom is exposed.
At least 70% of homecare is purchased by the State, so central government funding of councils for social care has a direct impact on the fee rates they are able to pay for homecare. In turn, these fee rates and the way homecare is commissioned and purchased, determines pay, terms and conditions of employment of the care workforce.
Scandalously low fee rates for homecare are paid by some public organisations, particularly in areas of highest deprivation, which do not enable compliance with employment or care regulations, never mind allow fair reward for the skills and experience of careworkers.
Zero-hour commissioning of homecare at low fee rates leads to zero-hour employment of careworkers at low wage rates.
It makes little sense to neglect people at home, wait until they reach crisis point, then admit them to the most expensive setting of care in an acute hospital. Here they may lose further function and require even higher levels of support and care when they are discharged back home, or to a care home.
Councils are unable to meet needs of all older and disabled people requiring help in the community. NHS trusts are struggling to reduce waiting lists, as timely discharge from hospital is hampered by inadequate capacity in social care and community services.
Greater investment is needed in homecare and community support to grow and develop the workforce and innovate, so we can enable people to live well at home, extend healthy life expectancy, reduce inequalities, take pressure off the NHS and reduce costs for the health and care system.”