Executive Summary

Case Management and The British Association of Brain Injury and Complex Case Management (BABICM)

The members of the British Association of Brain Injury and Complex Case Management (BABICM) work to support people who have some of the most complex and challenging disabilities, usually following life-changing injury.


The role of the case manager is to work to understand the individual scenario for each injured person and to use their professional skill and experience to ensure recovery is maximised alongside offering support, advocacy and guidance as each individual progresses towards overcoming the challenges they may face as a result of the changes their injury has wrought for their life, lifestyle and often their sense of identity.

The approach of the case manager is one of supporting individuality, autonomy, choice and control wherever possible and to ensure best-interest decision-making, minimally restrictive practices and the rights of each person when necessary, and thus the exact approach varies for each client. It is a role that often involves recruiting, training, supporting and supervising support workers to create enabling packages of care.

Case Managers work in many environments but the majority of the people that they support are living in their own homes in the community with bespoke teams of staff. This individualised approach to support means that injured parties can live full and rich lives where they can exercise autonomy, be spontaneous, have choice and fun. In addition adequate support reduces pressures on families giving relationships more space without family having to take on care roles. Not infrequently this is balanced alongside a backdrop of extremely challenging medical/clinical and social factors due to the changes caused by the person’s injury.

The support worker positions that case managers supervise are low-paid yet highly skilled and diverse roles requiring talented, motivated, exceptional people.


Rationale for the ‘Perfect Storm Survey’

Through conversations with members, BABICM recognised that there appeared to be ‘a perfect storm’ of increasing difficulty recruiting and retaining skilled support workers, this seemed to be worsening with no sense of levelling out. The recruitment and retention crisis appeared to result from a number of intersecting factors. There was frequently expressed concern about the impact of this on people with complex presentations following life-changing injury and on their families. In addition effects relating to the same issues were being felt by support workers and by case managers also.

The specific effects of this on clients highlighted to BABICM, included direct health, welfare and safety concerns, financial impacts on the cost of care and the potential for clients to run out of funds to meet their needs. Those involved in personal injury litigation were asking for information to inform their calculations relating to the future costs of care for cases yet to be settled.


Aims and objectives of the survey

The survey was constructed with the aim of gathering objective statistics alongside subjective narratives of the experiences of case managers recruiting and retaining support workers for their clients. Specific objectives were to be able to identify the range and frequency for payment of higher rates for support workers, the likely impact of mandatory vaccination for case managers, support workers and clients

BABICM was interested to understand how universally these issues were affecting case managed cases and to be able to use the survey results to articulate the issues members, their clients and support workers were encountering.

BABICM plans to share this information as widely as possible to support understanding of the issues clients with particularly complex disabilities, their families and the support work sector are experiencing. This will include highlighting to the medico legal industry the rates for support work that are now being asked for and paid.


Survey responses and findings

The survey was open for 5.5 days with email reminders and publicity across social media to encourage members to respond.

An unprecedented number of responses were received with an overall total of 202 by the close of the survey period. The number, speed and content of responses indicated the topic of the survey showed high levels of interest and concern for current and evolving situation.

Over 90% of respondents reported difficulties recruiting support workers. The responses contained remarkable similarity across themes and stories in responses to many of the questions asked.

The survey findings are presented and reviewed below;

Review of Survey

  1. Introduction:

The British Association of Brain Injury and Complex Case Management (BABICM) recently surveyed its members following concerns regarding recruitment and retention of support work staff, increased costs associated with recruitment and employment of support work staff, and the likely impact of mandatory vaccinations for staff. At the time the survey was undertaken the Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) (No. 2) Regulations 2021 placed a requirement on health and social care workers who have face-to-face contact with service users, including volunteers, to provide evidence that they have been fully vaccinated against Covid-19. This was due to come into effect on 1st April 2022 but, following an announcement in parliament on 31st January 2022, this requirement is likely to no longer remain in place.

The survey asked specific questions with Yes/No type answers and allowed for free text responses. One question asked for an assessment of likely increase or decrease of risk to clients.

13 questions were asked in total and the volume of the response to the free text questions was notable.

  1. Results: 
  • Respondent employment status

A total of 202 responses were received of which 129 identified as having “Case Manager” in their job title. Other more common responses included “Registered Manager”, “Director”, “Court of Protection Deputy” and “Clinical Lead”.

  • Is your organisation registered with the Care Quality Commission in England, Care Inspectorate in Wales or Scotland, or with the Regulation and Quality Improvement Authority in Northern Ireland?

A total of 200 responses were received of which 151 (75.5%) identified as being from organisations that were registered with an authority relevant for their territory. (49, 24.5% were not)

2.3   Have you experienced increased difficulty in recruiting support staff? 

A total of 199 responses were received of which 180 (90.45%) agreed that they had experienced increased difficulty in recruiting staff (9.55% had not)

  • What do you feel are the main issues? (regarding recruitment of staff)

A total of 195 free text responses were received to this question with varying but some very regularly repeated themes and comments.

Overall, the shortage of potential suitable applicants was noted as the main issue and was a very regularly repeating theme. Respondents who utilised agencies to source staff noted that they had increasing difficulties as the agencies were not able to attract and recruit staff.

The reasons for this shortage were identified as:

  • Low pay
  • Increased rates of pay in other sectors
  • Poor working conditions
  • The task is a skilled task and those skills are not seen as present in some/many candidates that do apply
  • Support Work agencies not being able to access staff
  • Loss of candidates and loss of some existing staff due to Brexit
  • Unsociable hours
  • Low status of employment, an undervaluing of the role of support worker/rehabilitation assistant. A sense that the career was not an attractive one.
  • Impact of the pandemic on the role
  • Introduction of mandatory vaccinations
  • Pre-existing crisis in recruitment (pre-Brexit and pre-pandemic)

The impact of low pay, Brexit, the pandemic, poor working conditions/status and mandatory vaccinations were most repeated themes.

  • Are you having to pay increased agency rates to access staff?

A total of 196 responses were received, 127 replied “yes” (64.80%), 69 replied “no” (35.2%)

2.5   What is the maximum that you have had to pay? How often are you having to pay this?

A total of 163 responses were received. Rates vary and costs between directly recruited staff and agency staff were noted.

Directly recruited staff rates vary between £13 to £21ph (majority of responses £14/15ph+)

Agency support work rates vary between £20 to £40ph

Agency nurse rates are reported to be £40 to £80ph but also noted to be between £500 and £1,000 per shift for last minute cover.

We have seen requests for 45% increases in pay. Given the need to occasionally use “emergency” cover agencies because of covid clients have had to pay over £40.80 per hour. We have had to provide greater incentives for staff to cover shifts at times this has included paying time and a half for emergency cover, double time and even offering triple time on Christmas day £61.60.

We increased the cost per hour for a recruitment drive. With no success. We are now looking at an agency which is £16p/h more expensive than what we were offering a directly employed worker.

I have had to authorise payments of up to £34.27 per hour for agency staff cover when a SW left to go back to the EU. Support for the client is for 7hrs p/day costing the client about £959.56 per week as opposed to £392.00 with employed worker who has now left. I have been unable to source suitable replacement and the recruitment drive is adding to the current care costs.

  • Can you provide any examples where this has been an issue?

126 responses were received to this question.

Issues with failed recruitment drives, not being able to source staff via agencies to cover and difficulties where funds are insufficient to pay for increased costs are noted. This has led in some instances to a reliance on family cover or community-based individuals having to move into residential care. The recruitment crisis is impacting upon Case Management costs.

I have other clients who need extra support on weekend daytimes and these roles have been extremely difficult to recruit into and remain vacant, despite increasing hourly wages. The same applies to part-time roles. Recruitment in these areas was always difficult but is even more so now. I have had to utilise agencies where I have been unable to recruit and in some cases this has meant significantly cutting the amount of support the client receives as the deputy does not feel the client can afford to pay the extra cost of an agency.  

I have a young ABI client that has not had support for the last 18 months, he is difficult to handle, and the burden has fallen on the family unfortunately to take care of him.

In order to get waking nights covered by a new agency who had taken over the CHC package I was asked to cover £1460 to cover hotel costs. The carer flew to Devon from Scotland! The agency covered other costs such as flights and additional time. There was no cover available in 12 agencies within Devon- the client has SCI and is ventilator dependent.

This increases significant risks to clients potentially being left unsupported and neglected and we have had to arrange emergency admission to care homes to address issues. Client admitted died of Covid in care home.

2.6    Have any safeguarding issues arisen as a consequence of being unable to access

necessary support staff? Can you provide anonymised details?

A total of 160 responses were received to this question. Some actual safeguarding issues were noted but, more regularly, less than ideal care, reliance on staff working extended hours, reliance on family was particularly noted. Impact upon quality of life for clients and increased risks were highlighted.

No safeguarding incidents because family members cover uncovered support shifts but this causes considerable problems because the family members are very unhappy that they are being put in this position.

A long-standing client of ours, who spent 13 years in locked units before we managed to house him in the community, has had to return to residential care. His clinical needs had changed slightly but we could not get the staff for him any longer, after more than a decade being managed in the community. His funds are low and we relied upon the State to fund the SW aspects of his care, they would not increase the wage rate to the one we thought was needed. More of a human rights issue than a safeguarding one.

Not on my cases, but I have heard of many in respect to other cases which colleagues have:

– many shifts being left uncovered, leaving vulnerable clients without appropriate support

– clients packages failing leading to admission to hospital and care home

– shifts being reduced in frequency or duration due to reduced available resources, sometimes resulting in the care agency resigning from the package due to being unable to resource it.

– payment of extortionate fees in the desperation to get cover for a shift due to management of risk

– families struggling due to increased pressure for them to provide care in the absence of formal support, leading to effects on their wellbeing as well as their family member

– refusal of entry to Essential Carers of clients in a care home as they have not yet received their third vaccine (as they were not eligible at the time) leaving the client with basic care in the care-home, where resources were massively stretched anyway and impacting on level of care and quality of life

– Difficulty getting calls answered in care homes to understand how the client is (whilst ill) as no-one has time to answer the phone

  • Do you anticipate further loss of staff as a consequence of a mandatory Covid-19 vaccination?

A total of 196 responses were received to this question, 161 (82.14%) anticipated that the recruitment/retention of staff would be impacted upon by mandatory vaccination.

Comments in response to this question were more varied and perhaps nuanced than some of the others where there was more uniformity of opinion. These included:

  • Some respondents noted their views that they agreed with mandatory vaccinations and highlighted risks to service users of non-vaccinated staff. Others were more reticent, noting the impact of loss of staffing, difficulties with recruitment and risks that would occur to clients who lost staff/could not recruit staff.
  • Loss of (or the risk of loss of) experienced staff was particularly noted.
  • A smaller group of respondents noted that they were at risk of losing their employment as they were not vaccinated for personal reasons.
  • Questions regarding the efficacy of the vaccine in preventing infection was also raised.
  • Figures of between 5 and 15% of support work staff being unvaccinated were mentioned.
  • Longevity of employment and the impact of, in some cases, decades of knowledge of individuals was raised.

I do not want staff who are antivax and welcome the legislation

I consider that the Covid-19 vaccination should be mandatory for health care workers to protect vulnerable clients.

Currently 15% of our clients SWs are unvaccinated or have not disclosed status, which is about 30 SWs, affecting 15 care regimes. Many of these are long term, highly trained staff who only work with one client who they’ve have managed to keep safe from COVID over the last two years. In all cases we consider that the clients (who are now vaccinated themselves) are more at risk from losing these staff than they are from catching covid from the staff member we will lose.

In a 24 hour care team of 9 that I currently manage, 4 are unvaccinated, including the team lead and I fear that I will lose all of them come the deadline. That will mean the client has to go in respite, if we cannot find a place and most probably hospital if not. 

There are increased risks to the health of some clients and maintaining care regimes in the community, as some experienced social care workers refuse to be vaccinated. The clients have been supported to be vaccinated and boosted. If these team members, some of whom have been trained over many years have to leave their employment, the client would be highly at risk and, in some cases, there could potentially be fatal consequences.

It is my consideration that, the preventive safety measures that my teams continue to take to prevent COVID 19 , is a more effective strategy than just relying on staff being vaccinated, if the preventative measure are adhered to having some support workers who are not fully vaccinated is a significantly lower risk than a depleted team which is then likely to break down, how can this be in my clients interests?

150,000 NHS workers are already anticipated to vacate their posts from 1st April, I anticipate this will be exacerbated in the case of Support Workers due to poor wage incentives as it is. Frankly, when a Support Worker can walk into Lidl and negotiate a higher wage with better hours, without the requirement of compromising their bodily sovereignty, I think we know where the incentive structure lies.

2.7 Do you think that case managers need to be vaccinated and do you see any

potential implications of not meeting the legislation and requirements?

From 193 respondents 72.02% agreed that Case Managers needs to be vaccinated and 27.98% did not.

  • Are you clear on which support staff would need to be vaccinated and your responsibilities in ensuring this? Do you see any potential implications of not meeting the legislation and requirements of staff?

From 191 respondents, 155 (81.15%) stated that they were clear about this point.

Comments in relation to mandatory vaccination varied and included:

  • A lack of comfort with the notion of “forcing” people to be vaccinated and the potential legal ramifications upon employers/Case Managers for doing so.
  • Recognition of the importance of legal requirements and duty of care.
  • A concern that the previous 2 years’ experience of successfully risk managing the virus was being ignored in favour of a mandated vaccine which had other risk implications.
  • Conflicted feelings between a belief in the use of vaccines but a further belief in choice for others.
  • A repeating concern about how packages will be able to continue to be managed with fewer staff both because of loss of existing staff and reduced ability to recruit.
  • Questions about who needed to be vaccinated, was this everyone who came in contact with our clients?
  • Concerns that this may push clients, families and Deputies to seek unregulated services which may circumvent the need for vaccination

Staff need to be vaccinated or provide an exemption. It is very clear.

I remain concerned that I will lose skilled trained experienced staff and not be able to replace them, over what I consider to be a short-sighted strategy. Adhering to preventative measure, irrelevant of an individual’s vaccine status seems to be a more effective strategy, to maintain an effective and safe care regime

This will only apply to staff under direct management and control of CM companies in regulated service areas. Therefore doesn’t apply to clients who receive support that does not fall under a regulation, ie dom care. Thus further complications with deputies whom we have spent years convincing that they need to use a CQC registered business may well be undermined as they potentially prefer to approach unregulated CM services in order to circumnavigate the issue.

I am NOT anti-vaccination; I (and 99% of my colleagues) were first in the queue but we respect others personal choice (and fears). We are not judgemental and hold the same beliefs for both customers and staff that they should be allowed choice and control.

2.8     Will this increase or decrease risks to your clients? (Mandatory vaccine issue)

This question was in the form of a rating scale of “decreasing risks” or “increasing risks” Respondents were able to pick a point on a sliding scale as to whether they believed risks would therefore increase or decrease risks on a scale of -100 to +100. 150 respondents replied.

  • 32 respondents believed that risks would decrease if vaccination of support workers was mandatory, 11 stated that risks would neither increase nor decrease and 107 believed that risks would increase.
  • When weighting the responses by perceived severity, the average increase in risk perceived by those who believed risks would increase, was by a factor of 59.68/100
  • When weighting the responses by perceived severity, the average increase in risk perceived by those who believed risks would decrease, was by a factor of 57.7/100
  • When combining weighted increase and decrease in risk, the overall average score was a perceived increase in risks to clients of 41.7/100
  • What are your thoughts about the future and issues that may arise?

153 replies were received, many of which repeated concerns that were raised throughout the survey. Broadly the following is observed:

  • Recruitment, with or without a vaccine mandate is noted to be increasingly difficult and this is attributed to a number of factors, the most significant are pay, Brexit, conditions, lack of availability of suitable candidates.
  • There is disagreement between members regarding the belief that the vaccination should be mandatory versus other methods of risk management, and other risks that are cause by loss of staff/failure to recruit staff.
  • The effectiveness of vaccinations is questioned.
  • Increased rates of pay, considered by the majority to be inevitable and required, has implications for funds/funding.
  • Increased difficulties recruiting has implications for costs of Case Management
  • Increased difficulties recruiting has implications with regards the necessity to rely upon family, with regards the possibility of maintaining some individuals in the community, and potentially with safeguarding.
  • Difficulties with recruitment are considered to be ongoing and without a solution in sight.
  • The vaccine mandate is considered to worsen the recruitment situation.

At the moment it feels this will compound already difficult factors. I can see Case Managers, as well as support workers, and many others in our industry leaving the profession. I feel the struggles will continue for quite sometime. I do not have much hope for the foreseeable future that things will change.

We often have difficulty recruiting care staff with the skills required. We anticipate this will prove even more difficult in the future.

With an already depleted carer pool, if everyone needs to be vaccinated we are going to lose additional staff. For some clients, risk of going without care is much higher than the risk of catching Covid. Where this is the case, if care teams struggle to maintain appropriate support, the legislation will actually be putting some clients at much higher risk.

I think pay rates will need to increase in order to attract staff, and recruitment issues have actually worsened since Brexit and the impact of this. The cost of living crisis will serve to put additional pressure to raise pay rates and I think mandatory vaccination is not the root cause of recruitment difficulties.

  1. Commentary
  • The survey link was only open for 6 days and received over 200 responses. This may be considered highly indicative that the issue of recruitment is a very taxing one presently for Case Managers.
  • The uniformity of responses with regards the impact upon recruitment and retention of low rates of pay, Brexit, employment conditions, the impact of the pandemic and the status of support work was significant.
  • The impact of recruitment difficulties is felt in terms of decreased quality of life and choice for service users, increased costs to service users/funders, increased reliance upon family support, increased Case Management time and costs, increased reliance upon more expensive services, increased risks, safeguarding issues, and loss of community placement. These were not expressed solely as concerns but as actually manifesting presently.
  • The nature of compulsory vaccinations to maintain employment/achieve new employment was seen by some as an ethical question, with views expressed across the spectrum from those who believed that this was a matter of personal choice to others who believed that mandating vaccinations was the correct course of action to reduce risks.
  • The impact of the proposed mandating of vaccinations was viewed by most as worsening an already difficult situation with regards recruitment and, as was often noted, the retention of good, trained and skilled staff already in post.
  • The possible loss of skilled and experienced staff anticipated by the mandating of vaccinations was considered to increase risks by some, particularly if this led to the loss of employment of skilled and experienced staff.
  • The reliance solely upon vaccination to manage risk of infection was highlighted by some as being unlikely to achieve the desired outcome.
  • The crisis of recruitment was considered ongoing with no end in sight and to have predated the law regarding mandatory vaccination. Increasing wages and improving conditions of work are suggested as necessary. Balanced against this is a recognition that funding is simply not available for some, in particular those with settled litigation claims or those reliant upon the State for funding/partial funding.