Through a glass darkly: the unseen crisis in home care

While pressures on the NHS continue to dominate headlines, a quiet crisis has been unfolding in the home care sector. Camille Oung describes how the system is likely to reach breaking point this winter, unless urgent action is taken.

Blog post

Published: 01/12/2021

The very visible and growing crisis in the NHS as we head towards winter has been the focus of many worrying news stories in recent weeks, with harrowing reports of people dying in the back of ambulances. But while that has dominated the front pages, a quiet crisis has been unfolding in people’s homes.

Pressures in the home care sector, which provides social care and support for people living at home delivered by some 500,000 people, have been bubbling unseen under the surface and are now at risk of boiling over. The home care system is likely to reach breaking point this winter, with far-reaching consequences for people and health and care services, if no urgent action is taken.

Why is the sector at breaking point now?

Long-standing pressures on council funding mean most home care providers operate on low margins. Home care providers were already operating on a shoestring when Covid-19 hit, with a limited capacity to withstand unforeseen shocks. They are now going into winter already torn down by the costs of the fuel and energy crises, and with difficulties in obtaining affordable insurance. Many run the risk of closing unexpectedly when costs overwhelm them and short-term emergency funding runs dry.

Demand for home care has risen over recent months. Covid-19 has made many people fearful of going into care homes and they have turned to home care instead. Councils and providers are also finding that people requiring home care are in need of more complex care as a result of early discharges from hospital and delays in people getting access to services.

Workforce shortages in home care are at a critical juncture

While the care sector has historically struggled to recruit and retain staff, many are now reaching exhaustion and burnout. We have already highlighted the scale of the unfolding workforce crisis across social care, and new published data, while limited, show the extent of these growing pressures in home care.

In the six months to the end of October, the number of staff working in registered home care providers recorded in experimental statistics fell by around 11,000 (2.5%), which is consistent with other estimates. However, this might substantially underestimate the true fall given not all providers submitted data during that period. As we highlight in our chart, these falls are worryingly apparent in other social care settings too.

Unless further action is taken, it’s likely we will see even more care staff leave this winter at the worst possible time. The sector is simply unable to compete with other industries able to pay more attractive wages, not least with retail offering attractive Christmas sign-on bonuses over recent months. Staff self-isolating as Covid and flu rates increase is a real concern. Some providers have already had to stall operations at very short notice due to widespread staff sickness.

And other wider systemic bottlenecks are heaping on the pressures. Home care is more dependent than any other part of the social care sector on staff who can drive. Given current delays to the processing of drivers' licences, the pool of staff from which providers can recruit is smaller than ever before – some providers have told us that as few as one in five applicants to home care jobs have a licence. People living in rural areas will be most affected by the absence of sufficient numbers of staff able to reach them.

Plans to make Covid vaccination a condition of employment, as has recently been introduced in care homes, could further contribute to staff shortages in home care if no effort is made to mitigate the potential consequences. If the government’s estimates of 35,000 home care staff leaving the sector as a result of the vaccination policy are accurate, we estimate that as many as 110,000 people could lose out on home care due to lack of staff. This is based on the average costs of care commissioned by the local authority and average hours of care provided by a home care worker.

What are the consequences? 

As pressures mount and waiting lists grow, many councils are worried that they won’t be able to fulfil their legal duties to assess people for care and maintain stable provision. We have anecdotal reports indicating that, across a large majority of providers of home care, demand is exceeding capacity and many are unable to take on new people in need of care. We are already seeing clear signs of this: more than 1.5 million hours of home care could not be delivered between August and October due to lack of staff. It is unclear whether there is sufficient capacity within the sector to manage if multiple home care providers suddenly shut down.

The reality of these pressures will be felt by many this winter, with more than 400,000 people already awaiting assessments or care. Already short visits could be shortened further to offer people only the very basic care, and people who are medically fit could be stranded in hospital for months as we are seeing in other areas of the UK. Unpaid carers, already exhausted, will be faced with increasingly complex caring roles.

We should heed warning of the consequences of inaction from our neighbours. In Northern Ireland, the crisis in home care is such that ministers are recommending that care home fees be waived to accommodate people stranded in hospital waiting for home care. This is an option of last resort and the impact of such policies on people should be carefully thought through.

Additional funding will be essential if providers are to be paid sufficient costs to stay afloat and the sector is to survive the winter. Addressing the enormous shortages in the workforce is a clear priority. Some funding has already been promised to support the retention of the home care workforce, and we are seeing councils using funds to pay loyalty bonuses to retain staff over winter. But, at just over £100 per head, the money that councils will see feels far from enough to make the difference. More radical thinking and leadership is needed from government at this point, who will need to consider everything from competitive retention bonuses to accelerating (or even subsidising) access to drivers’ licences for home care staff.

Government ministers cannot afford to be complacent about this crisis. Home care provides the foundations, along with other community services, on which much of health and social care is built. There is now an urgent need to shore up these foundations to prevent the further crumbling of the system this winter, and ensure that people are not left without a vital service that supports them to live well and independently.

Suggested citation

Oung C (2021) “Through a glass darkly: the unseen crisis in home care”, Nuffield Trust comment.