Opinion: Lynn Laughland, CEO HRM Homecare Services Ltd says Care at Home is at breaking point and paying people a more appropriate salary for the professional work they do is essential to putting the sector back on a sustainable footing. But, in the second of three articles for healthandcare.scot on fixing the sector, she argues that pay is only part of the answer.

“Across Scotland’s health and care landscape, there is broad agreement that the social care workforce deserves better pay, fairer conditions, and proper recognition.

Care at Home providers support efforts to raise earnings for frontline staff and improve the attractiveness of social care as a long-term career. These ambitions are not only welcome, they are also essential if Scotland is to build a sustainable workforce for the future.

But alongside that shared commitment sits an urgent reality that can no longer be overlooked: pay reform cannot succeed if it is built on an unstable market.

The Care at Home sector is already under sustained pressure, and providers are increasingly warning that even well-intended workforce initiatives risk accelerating service instability unless they are matched by a funding system that reflects the real cost of delivering safe care.

The fragility of Care at Home has not appeared suddenly, and it cannot be traced back to one policy decision, one difficult winter, or one moment of heightened demand.

It has developed gradually, through years of strain and accumulation. Chronic workforce shortages have become a persistent feature of the landscape rather than a temporary crisis. Need in the community has grown in both volume and complexity, as more people live longer, often with multiple conditions, and require more intensive support to remain at home.

At the same time, providers are expected to deliver care with schedules that do not always allow enough time to deliver safe, relational and person-centred support.

Regulatory expectations and oversight requirements have also expanded, placing greater demands on governance, quality assurance and documentation.

All of this sits against a backdrop of unreliable recruitment pipelines, an ageing workforce, rising attrition, and escalating operational costs across every part of care delivery.

Providers are not resisting change. They are not questioning the principle of improvement or the importance of valuing the workforce. What they are saying—quietly at times, more urgently now—is that a sector operating this close to the margin cannot absorb further pressure without becoming unstable.

Without stabilisation, change will not strengthen the system. It risks breaking it.

Improving frontline pay is essential and unavoidable. However, pay is only one part of the picture, and it cannot be treated as though it exists in isolation from the wider realities of care delivery.

For many providers, workforce costs already dominate the cost base. That means the system is highly sensitive to any shift in pay expectations, not because providers do not want to pay their staff more, but because many contracts are still commissioned at rates that fall short of the true cost of delivery.

In such an environment, even positive reforms can quickly translate into immediate financial risk. Providers can find themselves forced into difficult decisions, not because they want to compromise quality, but because survival becomes the primary objective.

This is where much of the public debate can fall short. It often focuses on hourly rates in a way that suggests Care at Home is a simple exchange: an hour of pay for an hour of care.

In reality, safe Care at Home delivery depends on a wide range of costs and capacity that rarely appear in headline figures, but which are fundamental to the service being safe, reliable, and resilient. Providers must maintain supervision and management structures, invest in training, shadowing and induction, and sustain ongoing recruitment and retention activity. They also need quality assurance and governance systems that allow them to meet regulatory expectations and safeguard the people they support. Care at Home brings unavoidable travel time and mileage costs, particularly in rural and remote areas, and requires continuity planning so that services remain dependable even when staffing is tight or demand rises unexpectedly. Alongside this sits compliance with statutory duties and employment obligations, all of which carry cost and complexity.

These are not optional extras. They are not inefficiencies to be stripped away. They are the practical foundations of safe care.

Yet too often, the commissioning environment assumes they can be absorbed within rates that leave little or no margin. Over time, that model shifts the system’s resilience onto providers themselves. It asks organisations to carry risk that would, in any other part of the health and care system, be recognised as a collective responsibility.

When viability fails, continuity of care fails.

The greatest danger of a fragile market is not simply organisational stress—it is service instability that is felt most sharply by the people who rely on Care at Home.

When contracts cannot be delivered safely and sustainably, the consequences become increasingly predictable. Capacity is reduced. Services are withdrawn from rural or hard-to-staff areas. Providers face rising turnover and workforce churn, which further undermines continuity and trust. In the most severe conditions, pressures can result in delayed visits or missed calls. Contract handbacks increase and unplanned transitions become more common, disrupting supported people, families, and unpaid carers.

These are not abstract risks. They are real experiences with real consequences for dignity, wellbeing, and safety.

Care at Home is also central to the wider functioning of Scotland’s health and care system. It is the backbone that supports people to remain in their own homes and helps reduce pressure on hospital discharge pathways. When it becomes unstable, the whole system feels the impact quickly, often in the form of delayed discharges, rising demand elsewhere, and a cycle of pressure that becomes harder to control.

A significant structural issue sits beneath all of this: the transfer of risk from the statutory sector to providers.

National ambitions for workforce reform, fair work, and improved standards are often communicated as system-wide priorities, and rightly so. But the operational reality is that many of these ambitions are implemented through contracts that leave providers to carry the financial and delivery risk. Providers become responsible for meeting nationally expected standards, while local commissioning approaches do not always reflect the full cost of doing so.

In effect, the statutory sector retains the authority to set expectations, but providers are asked to absorb the consequences when funding does not align with those expectations.

That imbalance creates an unsustainable pressure. It places providers in an impossible position: required to deliver more, to comply more, to recruit more, and to retain more, while operating on increasingly tight margins. Risk is not shared across the system—it is pushed outward, onto individual organisations, and onto the workforce itself. Over time, this does not lead to gradual decline. It leads to sudden destabilisation, as one provider after another reaches the point where the numbers no longer add up.

Scotland needs a stronger and fairer social care workforce. But workforce reform must be delivered through a model that supports not only pay uplift, but also provider viability, continuity of care, workforce stability, leadership capacity, and the quality and safety expectations placed on services.

Care at Home is not a “nice to have”. It is a critical pillar of community health and social care, and it will only be capable of delivering long-term reform if its sustainability is treated as a national priority.

If Scotland wishes to deliver meaningful change, then the sustainability of the Care at Home provider market must not be viewed as a side issue or an inconvenient complication. It must be recognised as a central condition of success, because without stability in delivery, even the strongest policy intentions will struggle to translate into safe, reliable care for the people who depend on it.

 

Lynn Laughland MBE is CEO of HSC Futures Ltd and HRM Homecare Services Ltd. As a guest contributor, her views are her own.

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