Why we must address inequality in social care, by Helen England, CEO

Posted: 6 October 2023

Brandon CEO, Helen England, shares her views on why we must address inequality in social care, and why we need a National Care Service.

Helen England

In this article:

  • Introduction
  • Integrated health and social care systems
  • Inequalities in the workforce
  • Why we need a National Care Service
  • Recognising support workers’ skills
  • Continued deficits for people who are already disadvantaged or equality for all?
  • Pay parity would benefit us all
  • Inequality in social care affects everyone
  • A call for action


I have worked in health and social care all my career, with a wonderful chapter in special schools thrown in during the early part of my working life.

I love that we have the privilege of being able to play a part in enabling the lives of our fellow citizens through good support, meaning that people can remain healthy, live as independently as they can, and with as much quality of life as possible.

Most of us recognise that at some point we will need to use the health service and as a nation, we value the fact that the NHS is there for us all. However, with significant demographic changes in the population, more of us, or those close to us, will also need the social care system at some point in our lives too.

Integrated health and social care systems

Image of a disabled person receiving heath and social care services. Includes the cover page of the NHS Health and Care ActThe law that underpins health and social care in England doesn’t change that often but only a year ago, a new act was approved through parliament, the Health and Care Act 2022. This was a major reform to the NHS and social care, which aimed to join things up for local people and communities so that outcomes can improve, and growing inequalities can be tackled.

Ever since I started working in health and social care, addressing inequalities has been a major national priority. The King’s Fund, define health inequalities as ‘avoidable, unfair and systematic differences in health between different groups of people’.

People with a learning disability and autistic people are among the groups that are most disadvantaged. On average, the life expectancy of a woman with a learning disability, is 18 years shorter than for women in the general population. And that gap is 14 years for men.

We also know, beyond any doubt, that health and social care are two sides of the same coin. It is widely recognised that a major constraint in allowing NHS resources to be used in the most valuable and efficient way, lies in access to and the availability of, high-quality social care in local communities.

The new Integrated Care Boards that resulted from the Health and Care Act 2022, have a responsibility to promote joined up health and care, and to reduce inequalities. But the changes are still not addressing a less visible but equally important dimension to the inequalities experienced by autistic people and people with learning disabilities: the inequalities experienced by the skilled and dedicated professionals who make up the social care workforce.

Inequalities in the workforce

In my recent interview for the Chief Executive role at Brandon, I asked people we support what, if anything, they would change about their support. There was a resounding agreement that while we have amazing staff, there are not enough of them and using agency staff instead is far from ideal.

I know, having worked in both the NHS and social care, that recruiting and retaining staff is a major challenge. However, the disparity in pay and conditions is now so stark that it is clear that health and social care are not valued as equally important components of the new integrated care systems.

The critical challenge is this – in the NHS, the Agenda for Change pay framework means that all staff undertaking work that requires a certain level of skill, knowledge and responsibility, get paid on the same pay band. In social care, no such standardised pay framework is in place. There is significant variation in the rates that different local authorities pay providers for care and support services that enable people, many of whom have complex needs, to live safely and remain well in their own homes. Therefore, there are different rates of pay for frontline staff, none of which adequately reward the level of skill, knowledge and responsibility they hold.

Why we need a National Care Service

A recent report by the Fabian Society, sets out a comprehensive plan for establishing a National Care Service. It describes not only proposals for ensuring that providers get paid fairly for the support they provide, but importantly suggests that a sector-wide fair pay agreement will be negotiated, with minimum rates of pay and employment conditions. Just as in the NHS, national pay bands and consistent employment terms are advocated.

This would be a seismic step forward for social care and for the dedicated staff working in this sector. It would not necessarily achieve complete parity with our NHS counterparts overnight, but would be a step towards greater equality and would better value social care staff for the work they do.

Recognising support workers’ skills

I was speaking to a brilliant young colleague of mine recently. She works as a support worker and is also training to be a learning disability nurse. She very clearly articulated the level of responsibility held by support workers in social care. Unlike a hospital environment, in which there are always more senior staff on hand, support workers often work autonomously in people’s homes. Brandon provides an exceptional learning and development programme for all staff throughout their careers, so they are fully supported to succeed in roles which come with significant responsibility.

Support workers are responsible for a wide-ranging set of tasks including the development of care and support plans, detailed record keeping, supporting the safety, health, and wellbeing of people in their own homes, as well as out in the community. They support people with personal care, their diet and specific dietary needs, and with food preparation. They administer and order medications and need to be able to follow policies and practice guidelines consistently.

Most importantly they need to excel in building relationships with people based on values and in facilitating choices that enable someone to have a great day, a fabulous trip out, or the holiday of a lifetime. Such relationships are built over weeks and months and years. They are relationships with depth and meaning and significance. That is what makes social care such a powerful part of our communities and wider society.

Continued deficits for people who are already disadvantaged or equality for all?

What an integrated care system could look like, and how different services could be linkedIt is remarkable that this disparity between two groups of staff, all of whom work in the same public system – health and social care – has become so stark. And it has far reaching consequences.

Better pay for social care staff would mean more staff working in the sector and better retention and continuity for the people supported. More capacity and resilience in social care would better support the NHS.

Having worked in the NHS for many years, I know that a significant contributor to the NHS being able to work well, is a concept known as ‘flow’. This means removing the constraints which prevent a person being able to go home and receive community support following a hospital visit or stay. Often this is down to social care but without that support being available, people stay for longer than is necessary in hospital. This results in the bottlenecks in other parts of the hospital which cause concern for many of my NHS colleagues, such as overcrowded A and E departments, or queues of ambulances delayed because they cannot transfer patients into the hospital.

Pay parity would benefit us all

Pay parity across health and social care, would unlock benefits not only for those working in the system, but for us all. Health and social care could function better, with increasing levels of confidence that anyone who needs care will find that it is available and accessible without undue delays or barriers.

And of course, if we can create a more stable workforce in social care, then people who already face major disadvantages within the health and social care system, will no longer face the double deficit of long-standing health inequalities coupled with the pay inequality built into their system of support, meaning it can become unstable.

Inequality in social care affects everyone

More than 30 years ago we agreed as a society, that people with learning disabilities should not be living in hospital wards. Social care is what allows people to live in their own home.

Being autistic or having a learning disability doesn’t necessarily make someone vulnerable. We know only too well that the people we support have gifts, talents, and many strengths, and they experience huge success in their lives. But it’s clear from the evidence that they are more vulnerable to experiencing inequality and as well as caring about this issue, we should recognise the wider consequences this has for society as a whole.

Gandi said that the true measure of a society is how it treats its most vulnerable. I hope that the measure of our society is that we will build on the progress achieved over the last 30 years, and sustain a social care system that supports people to remain and live well in their own homes. Pay parity for social care staff will help this to be a reality and will enable us to start addressing the other long-standing inequalities.

A call for action

This is the clarion call for action and it’s a call that is getting louder and gaining momentum. If you care about the future of the NHS, you must also care about the future of social care.

The NHS Confederation recently highlighted the impact of an under-funded and under-supported social care system on the NHS. And because they are two sides of the same coin, getting social care right will put the whole of our health and social care system on a much stronger footing for everyone, so that whether people need health care or social care, the right care is available for all. Isn’t that what we all want for our families?

Helen England
Chief Executive

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