When Alexander the Great encountered the impossibly complex Gordian knot, legend says he did not waste time unpicking it – he drew his sword and cut through it with a single stroke. Social care now faces its own Gordian knot: a thorny tangle of demographic pressures; workforce shortages; financial constraints; and competing political views.
The over-85 population will double within two decades. Meanwhile, the working-age population is shrinking. Retention and recruitment of UK care workers is hard, with 130,000 vacancies. Afraid of losing power to Reform UK, Labour has all but stopped international recruitment, cutting off a vital source of care workers.
Instead, Government wants to boost domestic recruitment by improving pay and working conditions. This is well intentioned, but 70-80% of care and support services are state funded, and public finances are strained. Cash-strapped councils and NHS bodies cannot afford to cover higher wages.
This creates a painful paradox. Rising employment costs without adequate funding means fewer people receive care, despite growing demand. Consequences cascade through the system: increased numbers of hospitalised older people; inhumane corridor treatment; and increased waiting lists. Labour’s funding decisions undermine its goals to shift from hospital to community and illness to prevention.
Higher employment costs without matching income risks regulatory non-compliance or bankruptcy. Employers cannot meet minimum wage requirements or deliver safe care if fee rates are too low. Many providers survive only by cutting corners. Lack of effective regulation allows non-compliance without consequence. Ethical, high-quality providers cannot compete.
Every attempted solution creates additional problems. Increase wages without funding? Fewer people receive safe care or any at all. Maintain current wages? Staff shortages worsen as workers move to other sectors with comparable pay but less responsibility. Rely on family carers? Many are already at breaking point, forced to quit jobs to provide unpaid care, further shrinking the tax base.
Like the Gordian knot, this situation calls not for incremental untangling, but for a solution that cuts through the problem. What might this look like? Firstly, recognise that social care contributes £68bn annually to the economy – creating high-quality jobs, reducing NHS pressure and enabling more people to remain economically active. Investment in care is a foundation for sustainable growth.
Secondly, we must move beyond the false economy of low wages. Keeping hourly rates low ultimately costs more through high turnover, agency premiums and preventable hospital admissions.
Thirdly, we must transform commissioning models. We could abandon traditional commissioning altogether. In Australia, people register on the Government website and local assessors determine level of need. People then receive a Government subsidy and choose their own care, like a self-funder.
Alternatively, we could move to Primary Care Network-linked neighbourhood contracts, lasting seven years for stability. These could include geographic zoning; guaranteed hours per provider; and payment in advance to allow payment of workers for shifts rather than per minute. We need a National Contract for Care Services with a minimum price for homecare.
Fourthly, we must embrace technology. Smart scheduling can optimise care worker time by 35% and cut travel by 65%, while remote monitoring and automated systems could help fewer staff support more people effectively.
Fifthly, have an honest national conversation about funding. Caring for an ageing population costs money, whether through a dedicated social care levy as in Japan, a social insurance model like Germany’s or Australia’s tiered funding approach with consumer-directed care.
We need a bold stroke. It is time to draw the sword.
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Dr Jane Townson OBE is Chief Executive Officer at the Homecare Association. Email: [email protected] X: @homecareassn