The Impact of COVID-19 on Social Care and Social Work in the UK: A Scoping Review

Abstract

Prior to the COVID pandemic, staffing levels, staff turnover and vacancies in adult social care and social work within the UK were a major concern, with staff experiencing high workloads, burnout, stress and poor morale. The paucity of published evidence in a rapidly evolving contemporary situation indicated the suitability of a scoping review. Systematic searching produced evidence published between 1 December 2019 and 9 May 2023. Out of ninety-seven articles retrieved, the final analysis included thirty nine articles. To report the review findings clearly and accessibly, the analysis used the Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework. Abundant evidence emerged on psychological distress and the impact of COVID-19 on the working environment for social care and social workers, but a paucity of psychosocial resilience, supporting social care managers, Personal Assistants and moral injury. Social care needs and the statutory duties of social work are likely to become even more intense. The COVID pandemic magnified a chronic lack of funding, staffing, support and regard for adult social care, with no future planning compared to the NHS. This legacy and backlogs of social care assessment and service delivery are of concern despite the proposed actions of the Adult Social Care Reform Act in England.

COVID-19, social care, social work

Introduction

The impact of COVID-19 on social care created global devastation. Research in Africa indicates the devaluing of the importance of social work relationships and commitment to social justice and human rights (Amadasun, 2020). Other research in Spain highlights rates of burnout, fatigue and depression amongst social carers (Luceño-Moreno et al., 2020). The concept of moral injury, because of exposure to morally injurious events, leaves a lasting impact on social care workers (Williamson et al., 2020). Throughout Europe, the impact of ‘social distancing’ exerted a profound change in social care and social work delivery (Devlieghere and Roose, 2020). In the USA, the pandemic exacerbated inequalities with more demand from social workers (Cross and Benson, 2021).

Within the UK, the pandemic placed increasing demands on the complex remit, scope and forms of delivery in the adult social care sector (Department of Health and Social Care [DHSS], 2020, 2021). This includes statutory and non-statutory service providers and interfaces with the health, private and third or voluntary sectors. The complexity of the adult social care delivery structures and the population it serves makes the sector both uniquely vulnerable to the long-term impacts of the COVID pandemic and potentially uniquely agile to embrace changes in working practice and service delivery.

Evidence since the start of the pandemic demonstrates an increase in domestic violence (Bradbury-Jones and Isham, 2020; Piquero et al., 2021), adult safeguarding concerning those most at risk (Anka et al., 2020; Cooper, 2020) and an escalation in mental health needs, creating additional impacts on health and social care services (Hodgson et al., 2020; Bhome et al., 2021).

Prior to the COVID pandemic, the shortage of over 110,000 health and social care staff and poor pay and working conditions created deteriorating morale, high workloads, burnout and poor pay and working conditions (Edwards and Marx, 2016; Dromey and Hochlaf, 2018; Kings Fund, 2018). Wales, Northern Ireland and Scotland reflect this situation (Scottish Government, 2019; Welsh Government, 2019; McMurray, 2020; Social Care Institute for Excellence, 2020; Skills for Care, 2021; UNISON, 2021). The known pandemic-related effects on the adult social care sector suggest the growth of social care service requirements (Dawson et al., 2020; NHS England, 2021) and a ‘tsunami of need’ post-COVID, questioning the availability of care (Thornton, 2020).

The pandemic exerted adverse effects on staff morale and well-being, with a rise in sickness absences across the sector and increased difficulties in recruiting staff from agencies, despite a pre-COVID government campaign (Skills for Care, 2021). Sickness, absences, recruitment challenges and increasing market fragility placed greater pressure on Local Authorities (LAs), increasing unmet care needs.

Social workers experienced moral challenges allocating resources for people with diverse and complex needs (Banks et al., 2020; Greenberg et al., 2020). One editorial claims that the pandemic created a reduction of bureaucracy and the emergence of more efficient ways of working for social care in UK LAs (Golightley and Holloway, 2020). The evidence appears conflicting, frequently failing to separate health and social care work. There is also a general lack of differentiation in reporting effects on the social care workforce, specifically social workers and statutory social work. Therefore, the aim of this review was to explore the effects of the COVID pandemic on the workforce, organisation, planning and delivery of social work and social care to adults in the UK.

Material and methods

Given the exploratory nature of this study and the relative lack of social care focused literature in this area, undertaking a scoping review enables a positive contribution to knowledge generation, informing current and future practice (Levac et al., 2010; Tricco et al., 2016). The study uses the reporting guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), specifically the extension for scoping reviews (PRISMA-ScR) (Tricco et al., 2018: Peters et al., 2020; Page et al., 2021). INPLASY published the protocol for this study: number 202230174 (Owens et al., 2022).

Eligibility criteria

Supplementary Table S1 illustrates inclusion and exclusion criteria for the study.

We chose to focus solely on the UK because of the differences in terminology and role descriptions in other countries for social care workers and social workers, resulting from different legislative structures, qualifications and professional status, alongside differences in service organisation, delivery and provision.

Search terms

To identify relevant evidence, consulting an information specialist optimised the key search terms, constructs; synonyms; and efficiency of the search strategy.

Medical Subject Heading entry terms for each selected database and modifying search terms occurred to suit the database specific thesaurus.

Search terms:

COVID-19 OR COVID-19 Pandemic OR SARS-CoV-2 OR Coronavirus OR 2019 nCoV Disease(s)

AND

Care, Social OR Social Care OR Support, Social OR Perceived Social Support(s) OR Online Social Support(s) OR Social Support(s), Online OR Social Support(s), Perceived OR Support(s), Perceived Social

AND

Work, Social OR Service(s), Social OR Social Service(s)

AND

Caregiver OR Carer(s) OR Care Giver(s)

Databases searched: MEDLINE, EMBASE, PsycInfo (all via OVID), CINAHL (EBSCO), Applied Social Sciences Index and Abstracts (ASSIA via ProQuest), American Psychological Association (APA), Websites for grey literature searching were Google (first 10 pages); Google Scholar (first 10 pages); Social Care Online http://www.scie-socialcareonline.org.uk/

Boolean operators and field codes enhanced the search for evidence from 1 December 2019 to 9 May 2023.

Identification and selection of relevant studies

Researchers used Covidence to import search results from each selected database, facilitating the initial screening and data extraction process and automatically removing duplicates. Using the eligibility criteria, selection followed a two-stage process: (i) three reviewers (R.A., A.P. and J.O.) carried out title and abstract screening. Evidence designated ‘maybe’, or where a conflict of opinion between the reviewers occurred, was subjected to a discussion to resolve any conflicts and reach inclusion consensus (ii) three reviewers (R.A., A.P. and J.O.) carried out full-text screening, for inclusion with conflicts resolved through discussion to reach consensus. Both stages in the screening process applied the eligibility criteria. Researchers recorded reasons for exclusion at either stage of study selection (see Figure 1). Covidence held all items in full-text version and further enhanced the efficiency of the study selection process, using tags and highlighting key words and phrases. Researchers uploaded a separate EXCEL spreadsheet charting the grey literature to Covidence, applying the same screening procedures.

Figure 1

PRISMA ScR flowchart of results. From: Page et al. (2021).

Charting and tabulation

Tabulation of evidence took place through a Microsoft Excel spreadsheet, which systematically recorded extracted study characteristics (Supplementary Table S2): (a) author and year of publication; (b) Peer reviewed (P) or Grey (G); (c) UK country of origin; (d) Research design; (e) sample size; (f) date study conducted; (g) type of social care worker.

Analysis

Analysis uses the Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework to report the review findings in a clear and accessible way (Bradbury-Jones et al., 2022). We produced a patterning chart based on inductively analysing key themes and sub-themes in the evidence base (Supplementary Table S3). Using reflexive questions around the pattering table such as what main themes arose from the analysis, what existing patterns arose and what areas presented little to no evidence, enabled the researchers to identify advances in the evidence-base, patterns and gaps. The analysis reflexively explored the impact of COVID-19 on social care and social workers.

Results

Out of 609 articles from databases and 34 from the other sources (N = 643), 544 were excluded leaving 99 full-text articles meeting the inclusion criteria for retrieval. Further assessment for eligibility, excluded sixty, leaving thirty-nine in the final analysis (see Figure 1).

Of the thirty-nine studies, evidence included twenty-eight peer-reviewed published papers and eleven reports or unpublished working papers (grey literature).

Research designs included four mixed methods studies, nineteen qualitative, one longitudinal and fifteen cross-sectional designs.

All studies took place between March 2020 and July 2022 (Table 1).

Table 1.

Type of worker described in the studies.

Name of worker	Number of studies
	N = 39
Social care (SCW)	18
Social workers (SW)	10
Social work students (SWS)	1
Principle social workers (PSW)	1
SCW and SW	5
Social care managers (SCM)	2
SCM & SW	1
PAs	1

There were more studies with older people in care homes and fewer about other populations. There were three main overarching themes in this scoping review. Psychological impact on workers in social care and social work; impact of the working environment on workers in social care and social work and potential future impact on workers in social care and social work.

Discussion

Patterns were further analysed in terms of advances, any gaps and recommendations for future research (Table 2).

Table 2.

Advances, gaps and recommendations (format guided by Bradbury-Jones et al., 2022).

Patterns	Advances	Gaps	Evidence for practice	Recommendations
1. Psychological impact on workers in social care and social work	Research focuses on psychological distress for SCW & SW (absenteeism, burnout, etc.).	Few studies use validated measures and explore risk and resilience factors together.	Focusing on psychological distress creates a one sided and negative perspective of psychological health for SW& SCW.	Research on risk and resilience factors using validated measures to address gaps and identify workers most at risk.
	The concept of moral injury is new in SW & SC. Early signs are that there is an impact on SW & SCW.	For SW & SCW, the lack of evidence base for a different organisational context lacks definition.	Using existing models for moral injury, which originate from the armed forces, creates a limited and incomplete evidence base.	Research to define moral injury within social care. Research to explore experiences and what reduces impact.
2. Impact of the working environment on workers in social care and social work	Inadequate support for management.	A paucity of research around ways of supporting managers.	Eliciting ways of supporting managers with their roles benefits managers, staff, service users and their supporters.	Research exploring supporting managers in carrying out their roles.
	Educational research on SSW produced varying accounts.	Research needed to evaluate ways SSW felt development of their skills enabled their future practice.	Post-COVID practice changed social work with the use of technology. Identifying how this affects the SSW informs long-term benefits for social work.	Action research on teaching and learning for SWS to evaluate the best ways of improving skills for social work practice in the current climate.
	PAs frequently left out of LA guidance and information because they did not possess a CQC registration number.	Evidence on PAs; how they receive important information and updates on working practices. How they negotiate their everyday roles.	The lack of evidence on PAs, potentially leaves them isolated and without recourse. Considering policy and practice for this marginalised group may help with their integration as a valuable part of social care.	Research with PAs in the UK, how they negotiate their everyday work in social care and stay updated.
3. Potential future impact on workers in social care and social work	Identification that no long-term social care plan exists in the UK.	Gap in evidence about coherent pathway for future planning in social care.	The NHS has a long-term plan, but social care appears devoid of a similar aim, further devaluing the importance of the work.	Policy research needed to outline a coherent pathway for future planning in social care.

Psychological impact on workers in social care and social work

Care homes and social work systems were poorly prepared for the pandemic and already struggling with existing challenges; a legacy of austerity measures (Hussein et al., 2020; Kierkegaard et al., 2021; Dixon et al., 2023). This is despite the promise of increased funding over ten years in ‘People at the Heart of Care’ (Department of Health and Social Care, 2021), underlining that social care is already underfunded, understaffed, undervalued and these issues stem from austerity measures, but became exacerbated during the pandemic (Age UK, 2020; Irving, 2021).

The additional impact on staff psychological health and well-being emerged from a lack of clear guidance from government about procedures to follow during the pandemic, which changed almost weekly, leaving staff feeling overwhelmed (Kong et al., 2021; Wheatley et al., 2021; Giebel et al., 2021a; Hanna et al., 2022; Kina and Luff, 2022; Baginsky et al., 2023). Furthermore, social workers struggled to juggle their work and personal lives while working from home, finding it difficult to disentangle home and work, reportedly feeling lonely and isolated, compared to healthcare workers who continued to attend their physical workplaces (GMB Survey, 2021; Kingstone et al., 2022). Working from home appeared flexible but simultaneously reduced learning opportunities (Kina and Luff, 2022). For social workers, psychological distress emerged from the reduced opportunities to provide and receive face-to-face support and an increase in levels of complexity experienced on caseloads (Manthorpe et al., 2021; Saloniki et al., 2022; Ravalier et al., 2023a,b). Research in the USA identified support systems and leadership as valuable in enabling staff to negotiate the pandemic (Miller et al., 2021). However, in the UK, support for social care staff and social workers appeared variable, with some workplaces introducing their own methods for ensuring staff well-being (McKenzie et al., 2021; Murray et al., 2021). Other workplaces left social workers and social care managers feeling isolated and alone (Manthorpe et al., 2021; Marshall et al., 2021; Kingstone et al., 2022), or failed to provide mental health support (Age UK, 2020).

There is an abundance of research on psychological distress for workers in social care, which fails to use validated measures and explore risk and resilience. This leaves a clear gap in the evidence. One benefit here may be to identify those most at risk and consequently improve support. Understanding the factors promoting psychosocial resilience (often termed as coping) may further assist with developing support.

Psychological rewards are important because staff invest time and effort into their jobs and expect rewards. Social Exchange Theory (Blau, 1964) suggests rewards in the workplace may be split into two different forms: economic (tangible) rewards such as pay or bonuses, which are clearly defined contractual and social exchanges. The other forms are symbolic rewards, which do not have any material value but have meaning for the recipient such as informal recognition for input (De Gieter et al., 2008, p. 99). One example of symbolic rewards is the ‘Clap for Carers’ campaign during the pandemic, which satisfies the need for recognition or achievement through public acknowledgement (Wood and Skeggs, 2020; ,Manthorpe et al., 2022). Skills for Care, (2021) provides examples of tangible benefits in terms of pay. With 380,000 social care workers on zero hours contracts with no guarantee of hours, no sickness and no holiday pay; these workers had no rights and experienced a precarious existence during the pandemic (Ravalier et al., 2017; Shallcross et al., 2021; Prout et al., 2022; Saloniki et al., 2022). However, zero hours contracts existed before the pandemic and some countries such as New Zealand outlaw them because they are exploitative. Although zero hours contracts are recognised in the Adult Social Care Reform White Paper as negatively affecting social care workers and the claim is to ‘build back better’ by ‘building supportive and inclusive workplaces’ (Department of Health and Social Care, 2021, p. 8, 102), little has been proposed to address this exploitative form of labour within social care in the UK.

One emergent area is that of moral injury, where social care and social workers perceive being in untenable situations, conflicting with their training and beliefs (British Association of Social Work, 2021). Research evidenced that during the pandemic, restrictions affected residents’ well-being, with limited or no family visits followed by a rapid decline in residents’ cognitive and physical health (Marshall et al., 2021; Giebel et al., 2022; Dixon et al., 2023). This precipitated a tension between care and ethics because in such difficult contexts, workers were unsure as to whether to withhold distressing information from relatives (Giebel et al., 2021a). Later research revealed the psychological impact on social workers who felt implicated in practices they regarded as unethical such as the discharge of COVID-positive hospital patients into care homes and the ensuing deaths of residents (Banks and Rutter, 2022; Giebel et al., 2022). A more recent judicial review concluded that this practice was ‘irrational’ and unnecessarily exposed vulnerable residents, contributing to additional deaths during the pandemic (Dyer, 2022). Legal judgement ruled that the rationale to free up beds quickly in the National Health Service (NHS) did not eliminate the need to consider the best way to manage those discharged and was therefore considered unlawful (Re Gardner and Harris v Secretary of State for Health and Social Care and Others, 2022). Social care workers observed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders recorded on peoples’ files without their consent, during the first wave of the pandemic, to free up hospital space (Briggs et al., 2021; Bows and Herring, 2022). Other research underlined that the pandemic restrictions failed to consider the needs of people with dementia or those at end of life (Dixon et al., 2023). These specific examples left social workers and carers feeling helpless to assist the people they cared for in a way they felt was ethical and humane. Feeling individually responsible (failing to prevent harm or mitigate distress) leads to negative internally directed emotions and ways of thinking such as guilt, shame or lack of self-forgiveness (Barnes et al., 2019). Unless resolved, these internal conflicts can exacerbate social problems (social isolation or aggression) and affect mental health negatively (depression, substance misuse and suicide risk) (Currier et al., 2015; Williamson et al., 2018).

Utilising the model of moral injury and measures developed by the armed forces in the context of combat (Nash et al., 2013; Nash, 2019) is a different organisational and situational context. This leaves a gap because the equivalent evidence base from which to draw in social care is lacking.

Impact of the working environment on workers in social care and social work

There was contrasting evidence suggesting that recruitment and retention differed markedly to pre-pandemic levels, with the legacy of staff shortages amplifying difficulties during the pandemic (Age UK, 2020; Marshall et al., 2021; Shallcross et al., 2021; Giebel et al., 2021a; Nyashanu et al., 2020a; Nyashanu et al., 2020b). One study provided positive evidence of improved retention of social care and social work staff during the pandemic (Skills for Care, 2021), but later identified it as an artefact of reduced job availability during this time (Skills for Care, 2022).

New information about personal assistants (PAs) in adult social care reported exclusion from guidance and access to PPE because they did not possess a Care Quality Commission (CQC) registration number (Norrie et al., 2022). Only a small minority received regular updates and targeted information about infection control and COVID, varying from LA to LA (Leverton et al., 2023).

The limited evidence on PAs, particularly in communicating changes to working practice leaves this group marginalised within social care. There is no imperative for unregulated PAs to update their training and knowledge, potentially compromising care. Developing policy and practice may assist with their integration as a valuable part of social care.

Abundant evidence emerged about the impact of COVID-19 on the working environment for social care and social workers, but a paucity on managers and the support experienced. Evidence suggested that managers felt isolated, working long hours with variable support from different LAs (Marshall et al., 2021; Bertini et al., 2023; Dixon et al., 2023). However, sample sizes were too small to make reliable inferences, leaving a gap in the social care evidence base.

Contrasting accounts also appeared from social work students (Sarbu and Unwin, 2021; Gillen et al., 2022). Social work practice appears to have changed post-pandemic, particularly with home working and employing technology; therefore, evidence needs to reflect the ways this affects students, their training and the future of social work.

Care home staff experienced significant changes to their roles during the pandemic, with little or no training to guide their transitions (Kierkegaard et al., 2021; Marshall et al., 2021; Giebel et al., 2021a,b; Hanna et al., 2022; Kapilashrami et al., 2022; Prout et al., 2022; Ravalier et al., 2023a,b). Social work assessment also expanded its online interface from previously recording information to greater use of online technologies for conducting assessments and new forms of virtual visitation, each producing its own challenges (Marshall et al., 2021; Giebel et al., 2021b; Kingstone et al., 2022; Pascoe, 2022; Pritchard-Jones et al., 2022). Globally, the adaptability of the social care workforce in rapidly changing their practices during the pandemic indicates that they are at the forefront of leading change in every country (Truell, 2020; ,McFadden et al., 2022).

Remote technology resulted in more time working rather than travelling and continuation of these positive consequences is expected to continue post-pandemic (Manthorpe et al., 2021; Kingstone et al., 2022), with greater use of digital technologies for adult social care as a key priority (Department of Health and Social Care, 2021). During the pandemic, the uptake of online and remote technologies improved the facilitation of cross-sector and multidisciplinary working between professionals and included more families, who lived at a distance, in assessments, care planning and review (Wheatley et al., 2021). The pandemic enabled social workers to recognise an increase in community and voluntary support, opening new avenues of working collaboratively within the community (Manthorpe et al., 2021).

Negative implications for social work included virtual assessments, which limited interpersonal communication, relationship building, reduced the quality of interactions and ability to observe and experience the home environment, which is crucial to holistic and informed assessment (Kingstone et al., 2022; Pascoe, 2022; Pritchard-Jones et al., 2022). The global evidence on social work suggests ongoing worries about assessing at a distance (Banks et al., 2020). Within the UK, backlogs of assessments remain with little indication as to how LAs can address the situation. Limitations become apparent in examples of digital poverty where IT equipment to enable such interactions was unavailable (Manthorpe et al., 2021). There is also evidence to suggest inhibited decision-making, with professionals excluding citizen involvement and making decisions about their lives under the presumption that they lacked the technology to facilitate their participation in their own social care (Duffy et al., 2022). The evidence implies caution and challenges the current Adult Social Care Reform White Paper (Department of Health and Social Care, 2021) which suggests that investing in and implementing the widespread digitisation of health and social care can support independent living and improve the quality of care, which clearly is not the case for all.

Practice changes with regard to the Coronavirus Act 2020, temporarily gave LAs the power to ‘ease’ their legal duties under the Care Act 2014 and the Mental Health Act 2007 in limited circumstances. Easements enabled LAs to temporarily reduce or withdraw care, support and statutory assessments without incurring a legal liability for a lack of statutory duty. The easements are a breach of the Equality Act 2010, which underpins all social work and social care practice in the UK. Notwithstanding, there remains little clarity on how LAs will address the backlog created by reduced assessments. One thing that remains is the magnification of chronic underfunding and devaluing of the social care sector during the COVID pandemic.

Potential future impact on workers in social care and social work

Lastly, no long-term plan exists for social care, with an underfunded, understaffed fragmented system (UNISON, 2021). The global evidence base reflects these worries, alongside the issue that COVID-19 highlights the role of socio-economic inequalities and the need to increase the capacity of social care (Amadasun 2020; Cox, 2020; Oakley et al., 2021). Therefore, the urgent development of a pathway for future planning should aim to minimise the impact on adult social care.

Limitations

Although researchers took care to ensure the search strategy was as inclusive as possible, to identify evidence fitting the eligibility criteria, possible unintentional exclusion of evidence may have occurred because of indexing or other reasons. A formal assessment of quality is not a necessary exercise for scoping reviews (Grant and Booth, 2009); therefore, we cannot comment on the overall robustness of evidence. We also excluded evidence treating health, social care workers and social workers as a homogeneous body of workers, because their roles are quite different and we may have missed some insights.

Conclusion

Pre-pandemic impacts on the social care sector exacerbated during the pandemic. Looking to the future, the implementation of the Integrated Health and Care Act in March 2022 enforcing the development of Integrated Care Systems, heralds a more strategic and operational partnership between the NHS and adult social care and with it an opportunity to implement lessons learned through the pandemic. However, the pandemic is not over. We have simply moved into a phase of learning to ‘live with COVID’, which has had and continues to have, a disproportionate impact on some populations and is amplified by inequalities in socio-economic status. If anything, social care needs and the statutory duties of social work are likely to become even more intense in the years that follow. Evidence of how social work and social care is now adapting to respond remains sparse, especially in the case of social work. High-quality evidence is required to address gaps concerning this complex workforce and its efficacy and adaption in the post-pandemic ‘living with COVID’ years.

Supplementary material

Supplementary material is available at British Journal of Social Work Journal online.

Acknowledgements

The authors wish to thank the National Institute of Health Research (NIHR) School for Social Care Research (SSCR) (grant reference number P169), for the funding to carry out this study. The views expressed are those of the authors and not necessarily those of the NIHR. The NIHR SSCR is a collaboration between the Universities of Birmingham, Bristol, Kent, King’s College London, Manchester, York and the London School of Economics and Political Science.

Ethical approval statement

Scoping review therefore none required.

Conflict of interest statement. The authors declare they have no knowledge of conflicts of interest for the study.