Public attitudes to social care in Wales following the COVID-19 pandemic

 

 

Research commissioned by Senedd Cymru and produced in consultation with Senedd Research

 

 

Dr Simon Williams1 2

 

 

1Department of Psychology, Faculty of Medicine, Health and Life Sciences, Swansea University, Swansea, Wales, SA2 8PP, Wales.

 

2Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA.

 

 

TOP-LINE SUMMARY

 

Study design

 

·         An online survey was completed by 2569 respondents between February 11th and March 11th, 2022.  Additionally, online focus groups were conducted with a sample of 14 participants.  The inclusion criteria were adults aged 18 years and over living in Wales

 

·         A limitation of the study is the lack of Black and Asian Minority Ethnic respondents.  Also, although respondent age range was 21-95 years, there was, relative to general adult population a disproportionately high number of older adults (average age = 64) (This likely reflects this age group’s greater interest in the topic).

 

Key findings

 

·         Four-in-ten of those who felt that they or someone in their household/close family needed social care during the past two years did not receive or make use of it.  The main reasons people gave for not receiving/making use of social care were: a lack of availability or staff shortages; the coronavirus pandemic; being deemed ineligible or otherwise not being offered care; not wanting to ask for help/being “too proud”; and the application or access processes being too complex.

 

·         Satisfaction with social care was variable, with approximately one-third either very or quite dissatisfied and a little over half either very or quite satisfied with social care services for themselves or a household or close family member.

 

·         The vast majority of respondents felt that the social care system in Wales was in need of reform (86%), and that reforming the social care system should be a priority for the UK and Welsh Governments (94%).

 

·         A significant majority of respondents felt that reducing the costs of social care for those that need it should be a priority for the UK and Welsh Governments (85%).

 

·         Nearly all respondents agreed that social care should be valued in the same way as health care (95%), and that social care workers should be seen as equal to health care workers (91%).  Most participants agreed that social care staff should have comparable pay (78%), working conditions (83%) and career progression opportunities (82%) relative to equivalent career stage NHS staff.

 

·         Respondents felt the pandemic has had a big strain on social care (mean=9.00) as well as on health care (m=9.24) (on a 1-10 scale, with 10 being ‘major strain’)

 

·         Respondents felt that a career in social care was not very attractive – both to them personally (m=3.42) or to others in general (m=4.08), and less attractive than a career in health care, to them personally (m=5.0) and in general (m=6.06) (perceived attractiveness rated on a 1-10 scale, with 10 being extremely attractive). 

 

·         Unsatisfactory pay, unsatisfactory working terms and conditions, unsatisfactory career security and progression pathways, better opportunities in other sectors, burn out/excessive work, lack of recognition or value given to the profession and the added strain of the COVID-19 pandemic on the social care workforce were all rated as playing an important role in the shortage of social care staff (M=7.16-8.29) (Factors rated on a 1-10 scale, with 10 being ‘it has played an extremely important role’)

 

·         The need for more consistency, personalisation, integration, recognition and investment in social care were all themes that emerged in the focus groups. Specifically, participants argued that there was a need for more consistency in the social care received, a need for more personalised care, a need for better integration between health and social care; and a need for more investment in social care.  Some felt that reform should see the integration of social care into the NHS, while others argued for the establishment of a separate ‘National Care Service’.

 

Implications for policy and practice:

 

·         It is concerning that approximately 4-in-10 of those feeling in need of social care did not receive or make use of social care services.  Social care policymakers and providers should seek to understand and address what people feel are the main barriers to accessing or using social care, including: increasing provision for those who need it; encouraging and enabling those who feel they need social care to apply (and working to de-stigmatise social care); consider broadening the eligibility criteria where appropriate; simplifying and providing more support for applying to/accessing social care.

·         Amongst participants in this study, there was considerable support for social care reform, for making social care reform a priority for government, and for reducing the costs of social care in Wales.  As such, any proposals and discussions for social care reform in Wales would likely be welcomed by many within the Welsh public.  In particular, there was considerable support for the idea of a more integrated and ‘joined up’ health and social care system, and one that was less reliant on private funding (e.g. via the incorporation of social care into the NHS or via the establishment of a ‘National Care Service’ for Wales).

 

·         Social care work was widely felt to be under-valued.  There was considerable support for improving the pay, working conditions, career and professional development opportunities, and ultimately recognition, of social care workers in Wales. Doing so could help the staff shortage problem and could help improve the overall satisfaction with services received.  Government and stakeholders should consider substantial reform in the training, accreditation, professional development and working conditions of social care workers.

 

·         The COVID-19 pandemic was widely felt to have caused considerable strain on social care.  It was also cited as one of the most common reasons as to why those who felt they needed care, didn’t or couldn’t access it during the past two years.  Major challenges for social care going forward include (1) Ensuring, and communicating to those in need, that adequate COVID-19 safety precautions and measures remain in place, as appropriate, in order to provide as safe as possible care, and (2) Addressing the added backlog that the pandemic will have contributed to, including those related to staff shortages due to illness and isolation and those related to COVID-19 policy measures.

 

BACKGROUND

The COVID-19 pandemic has shone further light on some of the challenges facing social care in Wales and looks to have exacerbated a crisis that was already extant.[1] [2] This has led to the intensification of longer-standing arguments that social reform is necessary and that the pandemic presents an added impetus and opportunity for reform.[3] [4]

 

In addition to an added demand, due to an ageing population and health inequalities, compounded by the pandemic, there are two main challenges facing social care in Wales: systemic challenges and workforce challenges.[5] 

 

A major systemic challenge is the fact that social care in Wales is currently provided by a number of different public, private and voluntary providers.  In particular, it is argued there is a need to ensure that social care provision is seamless, and that those using the services feel as though they are having a “single package”, tailored (personalised) to their needs - even where it is made up of multiple different providers, which can make governance, access and ultimately access complex.[6] [7] [8]

 

The major workforce challenges are the recruitment and retention of care workers.  For example, it has been suggested that social care is perceived as being a relatively low status job (e.g. compared to health care work).[9] It has been suggested that social care policy in Wales is dominated by a narrative of individual dependency and reliance, rather than discussed in terms of its social value and its connection to human rights, dignity and respect.[10]  Additionally, the COVID-19 pandemic has had a significant negative impact on the mental wellbeing of many social care workers, for example, anxiety related to perceived increased risk to themselves as a result of a lack of pandemic preparedness and infection-reducing measures and personal protective equipment (PPE).[11] [12] [13]

 

Stakeholders, including Care Forum Wales and the Wales Trade Union Congress (TUC) have called for additional funding for social care to enable social care workers to earn as much as comparable staff in the NHS combined with wider improvements to working conditions.[14] [15]   In its plan, A Healthier Wales, the Welsh Government has set out its vision of a ‘whole system approach to health and social care’, which is focussed on health and wellbeing, and on preventing illness.[16]  This includes developing “new models of care” which “strengthen the support, training, development and services available to the workforce with a focus on building skills across a whole career and supporting their health and wellbeing”.[17] The Welsh Government has recently announced further funding to enable a national recruitment campaign in order to increase pay and meet the real living wage in Wales, fund a national recruitment campaign and professionalise social care including improving career progression opportunities.[18]  The Welsh Government is also exploring the possibility of establishing a “National Care Service” for Wales.[19]

 

With these developments, debates and challenges in mind, and two years into the pandemic, there is a need for more evidence about people’s recent experience and perceptions of social care in Wales, including whether they have accessed services when needed, whether they were satisfied with care received, and whether they feel social care should be reformed, valued more, and how much they feel it has been impacted by the pandemic.

 

This research explores the following questions:

 

1.      What are participants’ experiences of social care in Wales? Specifically:

a.       For those that feel they, or someone in their household or close family, have needed social care over the past two years, did they receive or make use of those services. If not, why not?

 

2.      What are participants’ views on whether social care should be considered equal to health care in Wales? Specifically:

a.       Should social care services be valued equally to health care services?

b.      Should social care workers be valued equally to health care workers?

 

3.      What are participants’ views on the social care workforce in Wales?  Specifically:

a.       How attractive do participants feel a job in social care is to them personally, and to others in general?

b.      How attractive do participants feel a job in social care is relative to a job in healthcare (to them personally and to others in general)?

 

4.      To what extent do participants feel as though the COVID-19 pandemic has affected:

a.       The social care system and the social care workforce?

b.      The extent to which social care is valued?

 

 

METHODS

Participants

 

Eligibility criteria for this study were (1) Living in Wales; (2) Aged 18 or older.  Sampling for the study was non-probability, combining convenience and snowball sampling approaches.  Recruitment for the study was facilitated by HealthWise Wales (targeted research participant pool of 38,000 adults in Wales who have signed up to have research projects advertised to them).  Additionally, recruitment was supplemented via social media (e.g. Facebook and Twitter posts) snowball sampling, as well as through advertising via Swansea University press office (e.g. via study press release).  Focus group participants were compensated for their time with a £10 gift card.  Survey respondents were entered into a prize draw for an iPad.  Informed consent for focus groups and surveys was provided.  The study was granted ethical approval by Swansea University Department of Psychology’s Ethical review Committee.  As of 17th March 2022, 14 participants took part in the focus groups and the survey had received 2569 responses.  Participants’ demographic characteristics are reported in Table 1. 

 

Survey (n=2569*)

Focus groups (n=14)

Characteristic

N (%)

Characteristic

N

Gender

2501

Gender

14

  Male

896 (35.8)

   Male

7 (50)

  Female

1596 (63.8)

   Female

7 (50)

  Other

9 (0.4)

   Other

0 (0)

Ethnicity 

2513

Ethnicity 

14

   White

2473 (98.4)

   White

14 (100)

   Mixed/multiple ethnic groups

16 (0.6)

   Mixed/multiple ethnic groups

0 (0)

   Asian/Asian British

9 (0.4)

   Asian/Asian British

0 (0)

   Black/African/Caribbean/Black British

2 (0.1)

   Black/African/Caribbean/Black  

   British

0 (0)

    Other ethnic group

13 (0.5)

    Other ethnic group

0 (0)

Education (highest level)

2494

Age     M=63.9(SD=12.7) (Range=30-82)

 

    Postgraduate degree (e.g. MSc, PhD)

464 (18.6)

  First degree (e.g. BA, BSc, B.Ed.) or  

  equivalent

776 (31.1)

 

   HNC / HND / BTEC Higher, or equivalent

405 (16.2)

 

   A / AS levels or equivalent

182 (7.3)

 

   Apprenticeship

68 (2.7)

 

   O Level / GCSE grades A-C or equivalent

268 (10.8)

 

   O Level / GCSE grades D-G or equivalent

38 (1.5)

 

   Foreign qualifications

12 (0.5)

 

   Other qualifications

213 (8.5)

 

   No qualifications

68 (2.7)

 

Age        M=62.9(SD=12.5) (Range=21-95)

  

 

* The total number of respondents was 2569, but participants were not required to complete all survey questions and so specific numbers of respondents for each question are given.

 

Table 1: Demographic characteristics of participants in this report

 

Data collection and analysis

 

Surveys were conducted online via the survey platform Qualtrics.  The questionnaire included: background demographics; questions on whether they or anyone in their household/close family had needed care and made us of it, and whether they were satisfied with it; questions focused on participants’ views on the social care system in Wales (including their views on whether and how reform of the social care system is needed); participants’ views on the social care workforce, participants’ views on whether the COVID-19 pandemic has affected social care and people’s perceptions of social care.  A full list of interview and survey questions are available on request as supplementary materials.  Relevant survey questions are reported with data in the results section along with response category frequencies and descriptive statistics.  All data were kept securely and confidentially in line with ethics committee requirements in order to protect participants’ identities.

 

Focus groups were conducted online (via Zoom) and lasted approximately one hour each. Focus groups were audio recorded and transcribed.  Focus groups discussed participants’ views on social care in Wales, including their views on: social care reform in Wales; parity of esteem between social care and health care; the problems facing recruitment and retention in social care work; and whether and how the COVID-19 pandemic had changed their views on social care and how the pandemic may have affected social care work.  Following transcription, focus group data was analysed using a framework approach.[20]  This entailed inductively coding open-text survey data transcripts in order to generate themes as they emerged, informed both by the research questions and the initial survey results.  Focus group themes are presented below.  All participants were assigned pseudonyms to protect their identity.

 

RESULTS

Experience of and satisfaction with social care

 

Respondents were asked whether they felt they needed social care services over the past two years (since April 2020), and whether they had accessed or made use of them.  Overall, 261 (10.2%) respondents said they felt they had needed social care, and 560 (21.8%) respondents felt someone in their household or close family needed social care during this period.

 

 

Did receive/make use N (%)

Did not receive make use

N (%)

Total

N (%)

Needed care for themselves

159 (60.9)

102 (39.1)

261 (100)

Needed care for someone in household/close family

321 (57.3)

239 (42.7)

560 (100)

Table 2:  Proportion of respondents who felt that they or someone in their household/close family needed social care since April 2020, and whether or not they received/made use of it. 

 

Of those needing social care for themselves, 102 (39.1%) did not receive or make use of social care services, and of those who had someone in their household or close family who they felt had needed social care, 239 (42.7%) did not receive or make use of them (Table 2).

 

Respondents were also asked why they, or others in their household or family hadn’t received or made use of social care services, despite feeling they needed them.  The main reasons given included: no availability/staff shortages (e.g. “no carers available to look after my mother”, “was referred but LA [Local Authority] said too busy to do assessment”); being deemed ineligible/refused/not provided (e.g. “I was not offered the help I needed”; “there has been no emotional support for myself. Even though I am disabled with my condition worsening, the court didn't deem that I am. I never really received any support”); the impact of the COVID-19 pandemic on social care (e.g. “it was due to Covid they stopped coming to see me”, “I was afraid of catching Covid, I’m high risk”).  For those with family or household members who needed care but didn’t receive or make use of it, another common reason was not wanting to ask, due to a sense or pride or shame or stigma (e.g. “Pride, not wanting to be a burden”; “my Elderly mother fell I haven’t felt like bothering Social Services as media says how overwhelmed they are”.)  (Table 3).

 

Reason for not receiving/making use of social care

For themselves

N (% of 69 text responses)

For family member

(N) (% of 135 text responses)

 

Total

 

N (% of 204 text responses)

No availability/staff shortage

19 (27.5)

26 (19.3)

45 (22.1)

Deemed ineligible/refused/not provided

13 (18.8)

21 (15.6)

34 (16.7)

Didn’t want to ask (e.g. others need it more/pride/stigma)

2 (3.0)

28 (20.7)

30 (14.7)

Covid-19 pandemic

14 (20.2)

15 (11.1)

29 (14.2)

Application process too complex/didn’t know how

9 (13.0)

11 (8.1)

20 (9.8)

Miscellaneous/other

5 (7.2)

15 (11.1)

20 (9.8)

Waiting time

2 (3.0)

14 (10.4)

16 (7.8)

Family providing unpaid care

3 (4.3)

4 (3.0)

7 (3.4)

Cost

2 (3.0)

1 (0.7)

3 (1.5)

 

Table 3: Most common reasons why respondents who felt they, or someone in their household or close family, needed social care, didn’t receive or make use of it

 

Those respondents who had accessed social care, or who had someone in their household or close family who had, were asked to rate their satisfaction with the care received.  Overall, experiences were inconsistent, with approximately one-third either very or quite dissatisfied and a little over half either very or quite satisfied with social care services for themselves or a household or close family member (Figures 1a and 1b).

 

Figure 1b: Satisfaction with social care services amongst those who had someone in their household/ family use them
 
 Figure 1a: Satisfaction with social care services amongst those who used them for themselves 
 
    

 

 

 

 

 

 

 

 

 

Social care reform

 

The vast majority (86%) of respondents felt that the social care system in Wales was in need of reform, most of whom strongly agreed with this (60% of total respondents) (Figure 2a).   Similarly, the vast majority (94%) of respondents felt that reforming the social care system should be a priority for the UK and Welsh Governments, most of whom strongly agreed with this (72% of total respondents) (Figure 2b).

 

  

Figure 2a: The social care system in Wales needs to undergo reform
 
 Figure 2b: Reforming the social care system should be a priority for the UK and Welsh Governments
 

 

 

 


In terms of paying for social care, a significant majority (85%) of respondents felt that reducing the costs of social care for those that need it should be a priority for the UK and Welsh Governments, just over half (56%) of those responding strongly agreeing (Figure 3).

 

Figure 3: Reducing the costs of social care for those who need it should be a priority for the UK and Welsh Governments

 

 

Parity of esteem

 

Survey respondents also answered questions on the issue of ‘parity of esteem’.  Nearly all respondents (95%) agreed that social care should be valued in the same way as health care, with three-quarters of all respondents (75%) strongly agreeing with this (Figure 4a).  Additionally, nine-out-of-ten (91%) respondents felt that social care workers should be seen as equal to health care workers, with two-thirds (66%) strongly agreeing with this (Figure 4b).

 

 

Figure 4a: Social care should be valued in the same way as health care
Figure 4b: Social care workers should be seen as equal to health care workers
 

 

 

 


Respondents were asked whether they felt they now valued social care work more, compared to before the pandemic.  Just under half (46%) felt that they agreed (either strongly or somewhat) that they now valued social care work more, compared to before the pandemic (Figure 6).  Respondents were also asked about their views as to whether, compared to similar career-level NHS staff, social care staff should have comparable pay, working conditions and career progression opportunities.  Overall, most participants agreed that they should have comparable pay (78%), working conditions (83%) and career progression opportunities (82%) (Figure 5).

 

 

Figure 5: Participants’ views on whether they value social care work more now compared to the pandemic, and on whether social care workers should be comparable to equivalent career-stage NHS workers in terms of their pay, working conditions and career progression opportunities. 

 

To follow up participants’ views on the perceived impact of the COVID-19 pandemic on social care, respondents were asked a question directly on how much (on a scale from 1-10, with 1 being no strain and 10 being a major strain) the pandemic had put a strain on both social care services and NHS services in Wales.  Overall, they felt the pandemic has had a major strain on both social care (M=9.00(SD=1.35) and NHS services (M=9.24(SD=1.24) in Wales.

 

The social care workforce

 

Respondents were also asked questions on the issue of recruitment and retention related to the social care workforce.  Specifically, respondents were asked (on a scale from 1-10) how attractive they felt a career in social care was to them personally and to others in general.  For comparison, they were also asked how attractive they felt a career in the NHS was to them personally and to others in general (Table 4).  Overall, respondents felt that a career in social care was not very attractive to them personally (M=3.42(SD=2.48)) and to others in general (M=4.08(SD=1.70)), and less attractive than a career in health care, both to them personally (M=5.01(SD=3.06)), and to others in general (M=6.06(SD=1.91)).

 

Question

N

M

SD

How attractive is a career in social care to you personally?

1729

3.42

2.48

How attractive do you think a career in social care is to others/in general?

2058

4.08

1.70

How attractive is a career in the National Health Service to you personally?

1780

5.01

3.06

How attractive do you think a career in the National Health Service is to others/in general?

2090

6.06

1.91

 

Table 4: Participants ratings on the attractiveness of social care work and NHS work to them personally and others in general

 

Respondents were also asked what they felt the biggest reasons why people were possibly leaving or not applying to social care jobs.  They were asked to rate, on a scale of 1-10 how much of a role they felt each factor is playing in the shortage of social care staff (with 1 being ‘it hasn’t played a role at all’ and 10 being ‘it has played an extremely important role’) (Table 5).  Unsatisfactory pay, unsatisfactory working terms and conditions, unsatisfactory career security and progression pathways, better opportunities in other sectors, burn out/excessive work, lack of recognition or value given to the profession and the added strain of the COVID-19 pandemic on the social care workforce were all rated as playing an important role in the shortage of social care staff (M=7.16-8.29).  In particular, the added strain of the pandemic (M=8.29 (SD=2.01) and the lack of recognition given to social care work (M=8.21(SD=2.01) were the two highest rated factors.

Factor

N

M

SD

Unsatisfactory pay

2137

8.03

2.04

Unsatisfactory working terms and conditions

2127

7.89

2.02

Unsatisfactory career security and progression pathways

2123

7.16

2.19

Better opportunities in other sectors

2137

7.88

2.00

Burn out/ excessive work

2118

8.08

2.11

Lack of recognition or value given to the profession

2122

8.21

2.01

The added strain of the COVID-19 pandemic on the social care workforce

2123

8.29

2.01

 

 

 

 

 

 

 

 

 

 

Table 5: Participants ratings on the factors playing a role in the shortage of social care staff.

 

Qualitative findings

 

Focus groups also discussed the question of whether social care was in need of reform, what type of reforms they would like to see happen, whether social care should be valued in the same way as health care (parity of esteem) and why social care work was seeing problems in recruiting and retaining staff.

 

Five prominent, related, themes emerged: consistency, personalisation, integration, recognition and investment.  Specifically, participants argued that there was a need for more consistency in the social care received, a need for more personalised care, a need for better integration between health and social care; the need for more recognition for social care workers, and a need for more investment in social care.

 

Consistency

 

Participants drew on their experience of using social care, for example for a spouse or parent, to argue that, as they saw it, social care was not consistent enough.  Specifically, they argued that either the quality of care received was inconsistent (e.g. some care providers providing better quality care than others) or that there was a lack of “continuity” of care (e.g. a lack of communication or co-ordination between different care staff or care providers).  For example, one participant discussed how, as someone in full-time work, struggled to care for her mother, who required regular care that she felt was not met due to the lack of time allocated or because certain care staff were not permitted to undertake certain activities (e.g. helping with medical eye drops):

 

“What I found really sad was that my mom had dementia and there was no continuity … three times in a day she had the visit and you could have three different people, and that’s someone with memory issues. It was difficult to get a pattern. … As a family we were struggling to manage her condition because she needed these eye drops four times a day, and I work full time.  And so, the in-house provider was providing the care …… then the after so many weeks when our local manager was off, somebody else came in and said there was a note in the book saying ‘drops not given, we’re not allowed to do it. … Sometimes they didn’t turn up at all, saying they'd forgotten. … But you're afraid to complain you're afraid to complain in case you lose the service.” (Eira, Female, 60s)

 

As the above quote suggests, some participants felt as though it was difficult to make a complaint about the inconsistent social care they were receiving because they were “afraid” of losing the service. Others felt that it was difficult to complain about services, which they felt were not consistent or “joined up” because there was no clear or single person they could complain to:

 

“You certainly couldn't describe it [social care service] as in any way joined up … When my wife got to the point where she needed care at home, I was dealing with social services, but I didn't actually know where to start. it's not easy to navigate your way through, and you find yourself talking to different people at different times, but about the same thing. … and if you wanted to understand something more or make a complaint about how the way it worked, … you’d ring the local authority and you get to be a different person each different time. (Wynford, Male, 70s)

 

Personalisation

 

Participants tended to argue that although the care staff[21] themselves were often “good”, “sensitive” or compassionate”, the social care system and the way in which care services were managed or organized was felt to be “impersonal”, or even, as one participant argued, “callous”:  

 

“A couple of years ago my wife was diagnosed with motor neurone disease.  The carers we had, without exception were very, very good, very sensitive … but once you get into what you might call the management layer or the bureaucracy, you are simply a number and a case and they want you on one list or on another list. It's terribly impersonal – callous in a way.  You're in a situation where someone needs care, you only need care because the situation is critical to that person and their immediate family, and you immediately find you’re a commodity. (Wynford, Male, 70s)

 

Participants tended to argue that one of the reasons why it felt impersonal and not “joined up” (above) was because the system was “commercially driven” as a result of “privatisation” of social care which some felt “uneasy” about.  One participant discussed how there was more of a need to personalise and tailor social care to the needs of the family of the person receiving care, as well as the person themselves:

 

“They're caring for an individual, but they're caring for that family as well, because if the family is trying to support people to be at home, that package and the needs to be tailored around what helps everybody, you know. And I just found that the timing wasn’t helping me at all” (Eira, Female, 60s)

 

Integration

 

Participants argued that, in their experience co-ordination between health and social care services was lacking and should be better “integrated”:

 

“Healthcare social care should really be one service in a similar way. They should be knitted together (Denys, Male, 70s)

 

Participants argued that, from the perspective of those needing them, social care and health care were connected, because adequate social care could enable people to live at home longer and either avoid hospital for longer or leave hospital sooner (i.e. “bed blocking”):

 

“I think it is about integration, it's about bringing these things together … I think what the last two years has shown, it’s an unfortunate term, but bed blocking - it's shown the issues between health and social care and what can happen when it goes wrong, and if there's not enough capacity in both or how you move people through.” (Bryn, Male, 50s)

 

Some argued that they should be more “joined up” or “one”:

 

“There is no joined up process ….I think part of the bed blocking program that we're seeing is the result of the lack of joined up thinking and the lack of proper processes as to who's responsible for what part of the process of getting somebody out from a hospital environment.” (Diane, Female, 70s)

 

“I think that they, the NHS and social care, are regarded as two complete entities, and I believe that they should be one” (Enid, Female, 60s)

 

Others argued that social care should be fully integrated within the National Health Service:

 

“You can't describe it as part of the National Health Service, which I would have thought it was and ought to be.” (Wynford, Male, 70s)

 

Recognition

 

Focus group participants also discussed some of the perceived reasons why social care was experiencing difficulties in recruiting and retaining staff.  One of the main themes that emerged from the focus groups was that of recognition for the profession and its staff. 

 

A common argument was that social care was seen as a “secondary”, “fallback” or “Cinderella” service to the NHS, and social care workers were seen as “second-class citizens” compared to NHS workers.  Participants tended to feel that this was a perception that was unlikely to change fully, due to the fact that NHS staff were involved in “saving your life”, but that for them, social care staff played an important role in enabling people to lead independent lives:

 

“The general perception I've got of social care is that it's a fallback service …the NHS doctor or nurse is physically involved in the business of actually saving your life, the social worker is secondary, and I’m not sure that is a perception you are ever going to be able to change. … But on the other hand there are a number of things that the social care services do which enable people like myself and Enid and people of our generation lead independent lives, and we want to lead independent lives, but if the unavailability of social care means we are being forced into a care home or whatever, that is not the preferred option.” (Thomas, Male, 70s)

 

Relatedly, some participants argued that, unlike healthcare, which was perceived to be relevant to people of all ages, social care was primarily associated with “the elderly” meaning that many people didn’t see it as a priority, until they, or someone in their family, needed it:

 

“It [social care] most definitely does need to have more recognition.  If you ask people ‘do you want more buses, or do you want better social care?’ [they will say] ‘well I’m not really at that stage at the moment, so I'll have more buses. …  But if you ask do you want a GP practice in the area or do you want X, people will always choose a GP surgery … but they are intertwined.  [Social care] It’s a second thought.  … you only need it when you need it.  It shouldn’t be health or social care - it should be health and social care.” (Alys, Female, 30s)

 

Some participants also pointed to the fact that social care was, they felt, often portrayed in a negative light in the media, something that might be influencing their perceptions of it:

 

“Social work generally only really gets in the news when there's bad news … when its failing default you don't tend to hear much about the successes. Whereas the NHS is pretty much the reverse … certainly during the pandemic. … A lot of my views on the status of social care present time is largely based on this negative perception it's got.” (Denys, Male, 70s)

 

Participants also discussed how social care workers were, they felt, “undervalued”: 

 

“I think they're treated like second class citizens, basically in the workplace, that needs to change.” (Gareth, Male, 60s)

 

“They’re totally undervalued. I think it's exploitation.” (Diane, Female, 70s)

 

Participants argued that social care workers should get better recognition.  A common argument was that social care staff had increasingly been given less responsibilities and more restrictions on what they could do in the role.  Some argued this had contributed to an image of social care work as “menial” and a perception that the role had been de-skilled (or “dumbed down”):

 

“People seem to view it as something that you do if you can’t be a nurse, a very basic, menial job.  Mum’s been talking to her carers, and they have been doing it a while, the job’s been dumbed down, they have been given less responsibility and I think that is a problem, and if you want to encourage people into doing what is a very important job, you need to give them more responsibility, you need to put them on a parity with NHS staff, and just stress what an incredibly important job it is (Angharad, Female, 50s).

 

Many felt that the lack of recognition was associated with a lack of pay, and a lack of job security and a career pathway (“they need a professional route”):

 

“As I understand it, these folks are on minimum wage, on zero-hour contracts, … probably half the carers that we saw over the 18 months were doing the job because it was the only job they could get… And so, it struck me it's almost the employer of last resort. Social care … they are the Cinderellas in a way.” (Wynford, Male, 70s)

 

Some participants suggested that one way to improve the career development opportunities of social care staff was to provide a more integrated or permeable career path, such that social care workers could more formally and readily occupy similar or equivalent roles in the NHS, and vice versa.  One participant explained how this might help enhance the professional opportunities and abilities of both NHS and social care staff:

 

“Perhaps also a route between health and social care is a very similar roles, so that people can move between the two sectors … and lots of opportunities for that next level up. …. It would improve your personal and professional abilities to be able to see the world from the health, as well as the social care, point of view.” (Bryn, Male, 50s).

 

Some argued that the lack of remuneration had a negative impact on care staff motivation, and even ability, to undertake their role:

 

“Most carers I come across are fantastic. They are on very little money. You know I wouldn't do that job for the money they they're being paid.  So, most of them I take my hat off to but it's really sad when you see somebody who is has become cynical and poor at the job because you see the impact it's having on the person they are caring for. I think the whole thing has to be seriously looked at.” (Daffydd, Male, 60s)

 

Others argued that, despite their commitment to the role, people were leaving care roles because of the low pay and long hours, for work that was emotionally demanding and, during the pandemic, risky:

 

“You get paid more work at Lidl’s [supermarket].  I have family members who are carers [i.e. paid care staff] and they are 100% committed to those roles, but you know, you're struggling to pay your electricity bill.  My dad’s partner, she had to give it in because she would do a 15-hour day [and] she might see 20 people, providing personal care and up and down the M4 [motorway] caring for somebody that had no family and there was that emotional guilt … Going into the pandemic, they were asking them to put their own lives at risks with inadequate PPE [personal protective equipment], not enough money and no respite, and fear that they were going to bring it [the virus] home. (Alys, Female, 30s)

 

Investment

 

A fifth theme in the focus groups concerned the costs of social care, including how it should be paid for, and whether social care should be better funded.  Participants generally felt that social care needed more funding:

 

“It's not getting a big enough by to the cherry, but will it ever change?” (Gareth, Male, 60s)

 

Most participants also tended to express the sentiment that people should not have to bear too great a cost for social care, including recipients having to sell their home to pay for care.  They argued that, as with health care, paying tax and national insurance during their adult life meant that social care, or at least a greater proportion of it, meant they were, or should have been, already paying for it:

 

“Should someone's house be sold to pay for social care? I would think definitely not because people have normally worked hard all their lives.  If they've got a house, then they would like hopefully to leave it to their children or something like that, rather than the government stealing it to pay for social care. … Even as a pensioner I’m still paying tax and most all of my working life, I paid National Insurance so I should not be paying for any care I need in the future.” (Gareth, Male, 60s)

 

Some participants argued that the decision of whether, where and how to apply for social care should be shaped by what the recipient and their family needed, rather than by “financial pressures”:

 

“There's financial pressures around the system in all ways, and it would be nice to be able to remove those financial things away from the decision making and what's best for the individual what's best for the family.” (Bryn, Male, 50s)

 

As discussed above (see: Integration) some participants felt that social care should be integrated into the NHS, or that they should be considered one inter-woven service, while others specifically argued that a National Care Service working in a joined-up way with the NHS could ameliorate some of the current challenges that applicants or recipients experienced in trying to access, and pay for, care.  This they argued would reduce the stress that many families experience in trying to set up care:

 

I think there should be a National Care Service., whether or not, this is integrated into the NHS, I think the financials will come after - a more centralized structure, to get people out of the hospitals and into homes … as as opposed to desperately running around all the different care homes to see who's got a bed and to see what they've got. … It's a stressful situation … it would be nice to have one central information point.” (Bryn, Male, 50s)

 

Study limitations

 

Although there was a very wide age range of survey respondents – from 21 to 95 years of age – the average age of the sample was 64 years old (and a standard deviation of 12.5 years).  As such, it is important to note that, overall, the survey’s average age is older than the general adult population.  The recruitment and sampling strategy for the survey did not seek to be representative of the Welsh population, or to provide a random stratified sample. The survey was advertised to all adults on a large participant pool via HealthWise Wales, with all eligible individuals (all adults over 18) invited to take part.  It is likely that, with all non-random samples, a degree of response bias will be incurred.  In this instance, the larger number of respondents aged >50 years, and smaller number of participants aged <50 years likely reflects the fact that older adults will have more experience of social care, either directly as users themselves, or indirectly through a spouse, partner or parent who has received or needed care.  Also, it may reflect the common perception (as was discussed in focus groups) of social care as something that is associated with an older (or “elderly”) population, and as something that is only thought about “when you need it”.  As such, a challenge going forward is to promote greater and broader interest in, and appreciation of the value of, social care to the public, including younger adults.  As discussed above, and in more detail below, this could entail emphasizing how interconnected health and social care.

 

Also, there was an underrepresentation of Black and Asian Minority Ethnic (BAME) respondents in the survey.  This partly reflects the demographics of Wales - with 98% of participants in this described their ethnicity as White compared to 95% of people living in Wales overall.[22]  This is particularly important going forward, since there are a number of racial and ethnic inequalities related to health and social care in Wales, and BAME individuals may face additional barriers to accessing social care.[23] [24] Future research, including our own, should endeavor to use additional recruitment methods and outlets, and include messaging that suggests individuals from BAME communities are particularly encouraged to take part.

 

 

IMPLICATIONS FOR POLICY AND PRACTICE

 

From the perspective of the Welsh public, the COVID-19 pandemic has exacerbated the already significant strain on social care services in Wales.  Overall, this study has found there is a considerable appetite for social care reform in Wales.  Taking into consideration the scope of the research and the aforementioned limitations, a few main policy and practice implications can be drawn.  These will be discussed and summarized below.

 

Removing barriers to accessing or making use of social care

 

It is very concerning that approximately 4-in-10 of those who felt that either they or someone in their household or close family that needed help from social care, did not receive or make use of social care services.  This study provides further, Wales-specific, evidence of the ‘unmet needs’ that exist, where people who need care are not receiving or making use of it.[25]  Previous research on social care suggests that these unmet needs are related to a number of related supply and demand factors, including people in potential need of care not applying when they needed it and being denied access to services due to being deemed ineligible by social services'.  For example, research suggests that services may not be able to meet the needs of those who do apply or who are already in the system.[26] [27] [28]  Additionally, people may not be applying for support where it is needed, due to factors such as a lack of information about services available, a reliance on family or other unpaid care, and perceptions around the stigma attached to using local-authority-assessed social care.[29] [30] 

 

This study found that there were a number of barriers from the perception of the public.   Many people who had not received social care when they or someone in their household/family needed it because there was not enough provision or availability.  As such, extending provision through additional funding and social care workers could help improve access by those in need.  Secondly, some participants reported not accessing care because of the perception that there was not enough care services “to go around”.  In addition to ensuring adequate provision and availability of social care services for those who need it, government and social care service providers may also need to combat the belief that there is insufficient provision or that care should be “rationed” such that only those in greater need should be able to access it.

 

Unpaid carers play an enormously important role in providing care and improving the quality of life of those in receipt of their care.  However, this can come at significant cost to the carers themselves, including in relation to their own wellbeing.[31]  Many unpaid carers, and those who are receiving their care will understandably choose and prefer have care needs met at home, for example by a family member or close other.  However, the challenge for social care services is to ensure that this is indeed a preference, and not out of necessity (real or perceived) as a result of a lack of social care provision.  Also, many respondents reported that those in their household or close family who they felt needed care, but didn’t make use of it, didn’t do so because of a sense of pride – that is, of a negative association of local authority- provided social care or of going into a care home.  The best way to change negative perceptions of social care is to provide social care that feels both more personal and professional.  However, simultaneously, efforts can be made by all social care stakeholders, and society in general, to work towards shaping a more positive image of social care, and de-stigmatising the need for social care, such that those who are in genuine need of it do not feel “too proud” or ashamed of receiving it.

 

Another common barrier to access was the perceived complexity of the application process.  For some this was a deterrent to applying where they felt a genuine need for social care existed.  Streaming the application and administrative process and providing additional support for those who would like to apply for, or who receive, social care, but are unsure of various processes involved, would likely reduce the numbers of those who need care, but who are not receiving it.

 

Responding to the appetite for social care reform

 

This study suggests there is a considerable appetite for reform.   Overall most respondents in this study felt that reform of social care should be a priority for the UK and Welsh Governments.  There has been much dialogue in and outside of health and social care policy circles in Wales, and the UK generally, about the need for social care reform for some time.[32]  However, it has also been noted that many key reforms are yet to materialize.[33]   This perception, that reform has long been talked about but not yet enacted, was reflected by some participants in this study (“will it ever change?”).  As such, irrespective of what it specifically entails, social care reform would be welcomed by a large proportion of the Welsh public – and perhaps particularly by older adults (50+) who either are in receipt of care for themselves or others, or who are perhaps more cognizant of social care due to being of an age they consider more likely to need it in the near future.  Future research should seek to include a larger proportion of younger adults (<40 years), including via focus groups, to explore more deeply their views on social care. A broader challenge for social care reform, may be to address the perception that social care is “for the elderly”. Although focus group participants argued that health and social care were, or should be, inexorably linked, they also suggested that many people don’t really start thinking about it, or don’t see it as important “until you need it”. 

 

Arguments have been made that health and social care in the UK has been too disjointed and insufficiently integrated.[34]  Amongst participants in this study, there was a commonly held view that (because health and social wellbeing are inexorably linked) health and social care services should be better integrated and joined up.  As such, the present study suggests that a critical mass of the Welsh public, and certainly amongst older adults, may support genuine and significant attempts to more fully integrate health and social care in Wales.  This would add weight to arguments in favour of achieving the “seamless care” that is yet to be experienced by many in Wales.[35]  In terms of the nature of reform, this was explored in the qualitative data, with some arguing for better integration of social care into the existing National Health Service, and others arguing in favour of establishing a National Social Care Service, the care equivalent of the NHS.[36] There was significant support for reducing costs of social care, with many arguing that care should be indirectly funded (through tax, national insurance etc.) and thus free at the point of need.  As such, this would add evidence of public support for the impetus or rationale behind a National Care Service in Wales.[37]

 

Improving the pay, working conditions, career pathways and recognition of social care work

 

There was considerable support for moves to improve the recognition of social care workers in Wales, including considerable support amongst survey respondents for the idea of them being valued in the same way as NHS employees.  Focus groups brought out a more nuanced view, with participants suggesting that although social care work was unlikely to achieve the social status of front-line healthcare workers (who were “in the business of saving lives”) there was still a common feeling that social care work played an invaluable role in both freeing up hospital and health care capacity and, crucially, in helping people to attain a better quality of life, lead a more independent life, and reducing or sharing the caring responsibilities of families and unpaid carers.

 

Social care work in Wales is experiencing a number of challenges related to the recruitment and retention of care staff, including a high turnover of staff.[38]   A major cause of the shortage of social care work is its relatively low pay. Average earnings in the social care sector in Wales are approximately £16,900, compared to the national average earnings of

£29,200 (per full-time equivalent).[39]  Another issue has been the lack of integration of health and social care work and the lack of professional career development opportunities for social care workers (relative to health care workers).[40] [41]

 

Overall, participants felt that social care careers should be transformed – with better pay, better working terms and conditions (including secure, permanent contracts for care staff) and better career development opportunities.  Many felt that the best way to raise the status of social care work was to “professionalise” it, for example by adding educational and professional qualifications, coupled with clear career progression opportunities, akin to the ones they argued were available to health care workers. 

 

 

 

 

 

Mitigating the impact of the pandemic on social care

 

The COVID 19 pandemic has contributed to or worsened backlogs in health and social care in Wales.[42]  Participants in this study felt that the COVID-19 pandemic had placed a major strain on social care services.  This has had impacts on people’s willingness to access care, people’s ability to receive care, and the perceived quality of care received.  Unfortunately, those who have been most in need of social care are also include many of those who are also at highest risk of severe COVID-19 outcomes, including hospitalisation and death for example older adults aged 70+ and/or clinically vulnerable adults including those with certain disabilities.  As such, the pandemic may have created a new dilemma for some of those needing social care for themselves or their family: access social care and potentially increase risk of infection or not access social care and potentially experience worsening health or quality of life, and potentially place additional demands on unpaid carers as a substitute.  Additionally, some people have not felt they received the social care they needed during the pandemic, for example due to care staff or some services being unavailable in their area at the time or unable to attend due to COVID-19-related restrictions.

 

As with health care services, a challenge going forward for social care services may be a potential backlog of those needing care who were either unable to access care or receive sufficient care because of Covid-related staff absences and shortages or restrictions, as well as those who did not want to apply or re-apply because they were concerned about infection risk or because they did not want to “bother” services (or felt others were in greater need).  As such, services will need to look for ways of engaging, accommodating and supporting those whose care needs may have been postponed or disrupted due to the pandemic.

 

Summary

 

Drawing on the experiences and perceptions of participants in this research, the following implications can be drawn to inform policy and practice around the issue of social care reform:

 

(1)   Social care policymakers and providers need to understand and address the reasons behind why people who might need social care are either not able or willing to access it (roughly 4-in-10 in this study).  Particular attention can be paid to:

a.       Widening and clarifying eligibility criteria for social care.  Increasing provision such that all those in need of social care are able to receive it.

b.      Working to reduce the time delay between application and receipt of social care services.

c.       Simplifying the application and administrative processes for those in need of social care.

 

(2)   Making social care reform a priority in Wales.  Particular attention can be paid to:

a.       Reducing, or where possible removing, costs of social care services for people.

b.      Ensuring a more integrated, “joined-up” health and social care system.

c.       Consideration of integrating social care within the National Health Service or the establishment of a dedicated National Social Care Service in Wales.

 

(3)   Enhancing the recognition and attractiveness of social care work.  Including:

a.       Further improvements to the pay and job stability of social care workers.

b.      Improved working conditions and career development opportunities for social care workers (analogous to those in the NHS).

 

(4)    Mitigating the impacts of the COVID-19 pandemic on social care in Wales.  Including:

 

a.       Ensuring, and communicating to those in need, that adequate COVID-19 safety precautions and measures are in place, as appropriate, in order to reduce infection risk during care visits.

b.      Addressing the added backlog that the pandemic will have contributed to, including those whose care had been delayed due to COVID-19 policies/staff absences and due to people delaying their application. 



[1] https://www.theguardian.com/society/2020/feb/12/wales-social-care-home-crisis-councils-bankruptcy

[2] https://research.senedd.wales/research-articles/social-care-a-system-at-breaking-point/

[3] https://www.nuffieldtrust.org.uk/news-item/social-care-reform-what-is-the-vision

[4] Dowling, E. The Care Crisis: What Caused It and How Can We End It? London: Verso 2021.

[5] https://www.wcpp.org.uk/wp-content/uploads/2021/12/Challenges-and-Priorities-for-Health-and-Social-Care-Wales-Briefing-Note-.pdf

[6] https://gov.wales/sites/default/files/publications/2021-09/a-healthier-wales-our-plan-for-health-and-social-care.pdf

[7] https://gov.wales/sites/default/files/publications/2018-01/Review-health-social-care-report-final.pdf

[8] https://www.ijhpm.com/article_3790_fce0ce70c68441db088b5dda686927f8.pdf

[9] https://research.senedd.wales/research-articles/social-care-a-system-at-breaking-point/

[10] https://www.cardiff.ac.uk/__data/assets/pdf_file/0006/2569623/Tarrant-2021-Social-Care-Reform-in-Wales-Final.pdf

[11] https://www.tandfonline.com/doi/full/10.1080/20008198.2021.1882781

[12] https://www.tandfonline.com/doi/full/10.1080/13561820.2020.1792425

[13] https://onlinelibrary.wiley.com/doi/full/10.1111/hsc.13204

[14] https://research.senedd.wales/research-articles/the-real-living-wage-and-fair-work-what-are-the-latest-developments/

[15] https://www.tuc.org.uk/blogs/living-wage-care-workers-wales-start-not-enough

[16] https://gov.wales/sites/default/files/publications/2021-09/a-healthier-wales-our-plan-for-health-and-social-care.pdf

[17] https://gov.wales/sites/default/files/publications/2021-09/a-healthier-wales-our-plan-for-health-and-social-care.pdf

[18] https://gov.wales/96m-investment-give-tens-thousands-social-care-staff-1000-extra-payment

[19] https://gov.wales/first-step-national-care-service-expert-panel-announced

[20] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117368/

[21] NB: Participants references to ‘carers’ usually refer to professional care staff (as opposed to unpaid carers) unless otherwise noted.

[22] https://gov.wales/equality-and-diversity-statistics-2017-2019#:~:text=Main%20points-,Ethnicity,or%20'Other%20ethnic%20group'.

[23] https://www.wcpp.org.uk/wp-content/uploads/2021/03/Improving-Race-Equality-in-Health-and-Social-Care-Policy-Briefing-.pdf

[24] https://onlinelibrary.wiley.com/doi/full/10.1111/hsc.12116

[25] https://www.kingsfund.org.uk/publications/whats-your-problem-social-care#unmetneed

[26] https://www.health.org.uk/sites/default/files/NHS-70-What-Can-We-Do-About-Social-Care.pdf

[27] https://www.ageuk.org.uk/latest-news/articles/2018/july/1.4-million-older-people-arent-getting-the-care-and-support-they-need--a-staggering-increase-of-almost-20-in-just-two-years/

[28] https://www.cqc.org.uk/sites/default/files/20191015b_stateofcare1819_fullreport.pdf

[29] https://www.sciencedirect.com/science/article/pii/S0378512215300207

[30] https://socialcare.wales/cms_assets/file-uploads/Preventative-support-for-adult-carers-in-Wales.pdf

[31] http://eprints.lse.ac.uk/87978/

[32] https://www.ijhpm.com/article_3790_fce0ce70c68441db088b5dda686927f8.pdf

[33] https://www.kingsfund.org.uk/publications/whats-your-problem-social-care#unmetneed

[34] https://www.kingsfund.org.uk/publications/whats-your-problem-social-care#unmetneed

[35] https://gov.wales/sites/default/files/publications/2018-01/Review-health-social-care-report-final.pdf

[36] https://www.bmj.com/content/365/bmj.l4349.full

[37] https://gov.wales/first-step-national-care-service-expert-panel-announced

[38] https://gov.wales/sites/default/files/publications/2020-06/welsh-government-response-to-shortage-occupation-list.pdf

[39] https://socialcare.wales/cms_assets/file-uploads/The-Economic-Value-of-the-Adult-Social-Care-Sector_Wales.pdf

[40] https://gov.wales/sites/default/files/publications/2018-01/Review-health-social-care-report-final.pdf

[41] https://socialcare.wales/cms_assets/file-uploads/Workforce-strategy-ENG-March-2021.pdf

[42] https://www.bevancommission.org/publications/doing-things-differently-tackling-the-backlog-in-the-aftermath-of-covid-19/