The care crisis and why it affects us all speaks to Jane Townson of the Homecare Association about the carer shortages and the impact on healthcare and employment.

Caregiving Nurse putting a bandage on a senior mans arm in his home.


Poor wages in the domiciliary care sector are contributing to large numbers of carers leaving the workforce and are causing knock-on effects across health and social care as well as putting huge pressure on informal carers, many of whom will be trying to hold down a job while caring for a relative.

As the Country Councils Network – a group of mostly Conservative councils – warns of serious crisis in adult social care, figures from the Homecare Association released this week show the average fee rate paid for homecare in England by local authorities was £19.01 per hour in April. The average fee rate paid for homecare in England by the NHS was £18.76 per hour. The association says both figures are substantially below its Minimum Price for Homecare for 2022-23 of £23.20 per hour. This money has to cover not just the carers’ costs, administrative costs, IT, insurance, training and recruitment among other things.

Around 70% of homecare is purchased by the public sector, meaning central government funding of councils and the NHS has a  direct impact on the fee rates they pay and what they can pay carers. Another factor that affects take home pay is mileage for carers travelling between jobs. It’s much lower for domiciliary carers than NHS workers. Moreover, while travel time is counted as working time for national minimum wages purposes, public sector commissioners pay for client contact time only and providers have to make the fee rates stretch to cover all working time, not just client contact time. That can make it challenging to pay careworkers enough to ensure fair wages for all their working time. What’s more, some employers don’t pay for time spent training.

In addition, domiciliary carers are often on zero hours contracts so, for instance, if a client is in hospital and they aren’t needed they could end up losing pay despite the fact that demand for their services is rising.  Part of the problem is that it can be hard to move a carer between clients due to the nature of the relationship. What’s more many carers are paid by the minute rather than per shift, which the Homecare Association says equates to paying for the process rather than for outcomes.

Finances and funding

Due to rapidly rising fuel costs and high levels of inflation, many homecare workers are moving to jobs in retail and hospitality. Skills for Care recently reported a decrease in filled posts of 50,000 in the social care workforce in 2021/22 compared with 2020/21. The homecare vacancy rate has reached 14.8% this year, the highest ever recorded.

While she says central government funding is the key issue, Jane Townson, CEO of the Homecare Association, says some councils could do a better job. She notes that councils with the highest deprivation levels often have the highest need for carers and the lowest fee rates which compounds inequalities. However, she says some councils don’t prioritise care. Another issue is an underlying structural one. Townson says that the workforce is fragmented which makes it difficult to operate efficiently. “It’s not possible to do it in an efficient way due to the way it was set up,” she states.

All of these problems are coming at a time of increasing need as the population ages – Townson says that, despite pockets of good practice involving multidisciplinary teams, the service can’t cope now, let alone when demand rises, but she fears there is little real political interest in improving the service for the longer term. 

Then there is the spiral effect. When people can’t manage at home they move into care homes. However, care homes face similar staffing problems to domiciliary care and some are reducing services or even closing as a result. That puts more pressure on hospitals, with longer periods of hospitalisation resulting in more infections and longer queues for ambulances because people cannot be discharged unless there is a care package in place.

“If the UK was a company the whole board would have been fired,” says Townson, who used to run a care agency. In addition to adequate funding, she would like to see a lot more vision and innovative thinking, for instance, remote health monitoring and other uses of technology and new ways of working.

Informal carers

In the meantime, a lot of the care burden is falling onto informal carers. It is estimated that in the UK 13.5m of the circa 15m people who receive or need support and care at home get that support from informal carers, compared to around one million who receive paid homecare and around half that number respectively who are in hospital or in care homes. The Homecare Association says it is estimated that over a million people are missing out on the care they need altogether. 

Many informal carers who are over 50 have left the workforce as a result of their caring responsibilities, with Covid exacerbating this. Many other over 50s have dropped out of the workforce due to long term health issues. The care spiral is overflowing into the workforce, with employers facing labour shortages and employees facing burnout because they are often doing more than one person’s job.

Some employers recognose the pressure many are under and are providing support to carers, including paid carers leave and passports. 

One such is Phoenix, which has a carers network. Denise Turnbull who chairs it has been a sandwich carer herself, looking after her mum who had dementia and her daughter who has autism. In addition to 10 days of paid carers leave a year and a very flexible culture, the network offers peer to peer support. For Denise this has been invaluable. She says: “If I had not had such an understanding employer I would maybe have had to leave my job.”

Employers can only do so much, however, and experts argue that having a care service that works is fundamental for a productive economy. The Women’s Budget Group called for a care-led recovery after Covid. That doesn’t seem to have materialised.

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