Health and Social Care Committee
Oral evidence: Social care: changes to legal migration measures, HC 411
Tuesday 19 December 2023
Ordered by the House of Commons to be published on 19 December 2023.
Members present: Steve Brine (Chair); Rachael Maskell; James Morris.
Questions 1 - 35
Witnesses
I: Professor Martin Green, Chief Executive, Care England; James Bullion, Chief Inspector of Adult Social Care and Integrated Care, Care Quality Commission; and Oonagh Smyth, Chief Executive, Skills for Care.
Witnesses: Professor Martin Green, James Bullion and Oonagh Smyth.
Q1 Chair: Good morning. This is the Health and Social Care Committee, live from the Palace of Westminster on 19 December. It is our last session before the Christmas recess, which kicks in later today, subject to the passage of business in the House. This is one of our topical sessions, so it is not part of an ongoing inquiry. It is exactly what it says on the tin, having been prompted by the Government’s new measures on legal migration that were announced on 4 December. We have three guests joining us today: Oonagh Smyth, chief executive of Skills for Care, who is joining us virtually—thank you very much, Oonagh. We have James Bullion, who is chief inspector of adult social care and integrated care at the Care Quality Commission. It will be obvious as we progress why the CQC is here today, given that it formed part of the announcement on 4 December. Lastly, we have Professor Martin Green, who is chief executive of Care England. Thank you very much for joining us, all of you. We are a perfectly formed, select but quorate group of the Health and Social Care Committee this morning.
Earlier this month, the Government announced a series of changes in what they called migration week. On 4 December they announced changes to UK legal migration rules as part of plans to cut net migration by 300,000—their figures. The Home Secretary set out to the House a five-point plan. I will read the first bit of it, for those watching. You know this, we know it, but not everybody watching may be familiar with the exact detail: “The first point of our five-point plan will be to end the abuse of the health and care visa. We will stop overseas care workers bringing family dependants, and we will require care firms in England to be regulated by the Care Quality Commission in order to sponsor visas. Approximately 120,000 dependants accompanied 100,000 care workers and senior care workers in the year ending September 2023. Only 25% of dependants are estimated to be in work, which means that a significant number are drawing on public services rather than helping to grow the economy. We recognise that foreign workers do great work in our NHS and health sector, but it is also important that migrants make a big enough financial contribution. Therefore, we will increase the annual immigration health surcharge this year by 66%”—to just over £1,000—"to raise on average around £1.3 billion for the health services of this country every year.”
Health and care visa routes will continue to be exempt from the increase in the skilled worker earnings threshold, which is going up to £38,700. That is what the Government announced and we discussed this briefly, as you may have seen, with the Secretary of State and the permanent secretary last week. I will start with you, Professor Green. I suppose the first question, which is an easy early field of the ball, is: what did Care England think when it heard that announcement?
Professor Green: We were very concerned about the announcement. We are particularly concerned about the issue of bringing dependants in. That is because people often need to have their family in order to settle in. We were also concerned because we have chronic workforce shortages in social care. I am sure that Oonagh Smyth, from Skills for Care, will outline some of that. We are in a position where we cannot recruit staff in some areas. Not only is that having an impact on services but in some areas it is reducing capacity. I have members who have had to reduce the numbers of people they support because they cannot get the staff.
We were very concerned about all those aspects of the changes. We were particularly concerned, annoyed and irritated that those changes seem to have come without very much, if any, consultation with the sector. It would have been much better if the Government had been more collaborative, had come to talk to us and had understood the implications of the changes before announcing them. Unfortunately, they did not do that, so we were all a bit blindsided.
The final point I want to make is that this has caused a great deal of uncertainty for people who are already here who thought that they might be able to bring in their dependants. Of course, the other part of this, which links to the dependants issue, is that the Government have allowed NHS staff to continue to bring dependants in, but not social care staff. We see endless discussion about integration, but we never see that translated into policy. During covid, we saw the rule that all care home staff had to be vaccinated, but staff in the NHS did not have to do that. The impact was that people left social care and went into the NHS and other sectors. We have grave concerns that that will happen as a result of this policy; because they cannot bring in their dependants, people will move away and go into other sectors, where they can.
Q2 Chair: Professor Green, I wish you would say what you think. We will come back to you shortly.
Oonagh Smyth from Skills for Care, what were your organisation’s initial thoughts when you heard what I just read out what was said in the House on 4 December?
Oonagh Smyth: Thank you, Chair. Skills for Care does not take a position on whether international recruitment is the right policy choice, but our evidence, which covers about half of the social care workforce, shows really clearly that international recruits have significantly contributed to workforce capacity. In the year March ‘22 to April ‘23, we saw about 70,000 international recruits and an increase of about 20,000 in the total net workforce numbers so, while we had more recruits, we had only 20,000 net workforce growth. It is fair to say that international recruitment has helped despite domestic recruitment and retention issues.
Expanding that to look at the year before, we have lost about 90,000 domestic recruits since 2021-22, some of whom will have gone elsewhere when the labour market opened after covid. If we reduce international recruitment, it is clear that we will have to do more to recruit and, importantly, retain our domestic workforce, because demand will only grow over the next few years as our populations grow and as we live longer but not necessarily healthier. International recruitment being reduced will mean that we will really need to take a look at workforce capacity in the short term, and, importantly, in the medium and longer term.
Q3 Chair: Mr Bullion, one element that I think has been broadly welcomed was that care firms in England will be required to be regulated by the CQC in order to sponsor visas, and obviously they are already regulated in a caring capacity. That is because the Government believe that there is abuse of that visa route such that people are working on that visa for very short periods of time and then moving into other parts of the economy. There is some semblance of truth in that, isn’t there? What was your initial response when you heard the announcement?
James Bullion: Like Martin and Oonagh, I absolutely recognise that there is a long history in both health and social care of international recruitment contributing to the workforce. There is really a dependency now and an interdependency, which goes right back to Windrush, on that recruitment bringing people to work in public services and social carers ancillary to that. In CQC, our concern is to make sure that the impact of this new approach is not to worsen the vacancy situation but to contribute towards or ensure a sustainable workforce.
As a regulator, we are concerned and want to make sure that any abuse of international recruitment and any unethical recruitment as part of regulated activity is minimised. I understand the logic of why there may be a link with CQC registration. I would point out, however, that social care is widely defined. It is not just the services that CQC regulates. We regulate home care and residential care, primarily. Social care is a slightly wider interpretation. It includes personal assistance; live-in carers; people working in residential settings that are not regulated activities, such as Shared Lives; drugs and alcohol services; and domestic refuges. All those care workers, who may have been recruited internationally, will not fall under registration for CQC because our regulations are not proposed to change under these proposals. There is an issue here of fit and of making sure that the work we do as a regulator covers and is or is not in scope.
Q4 Chair: Are you clear exactly how the regs will change? Have officials been in touch with you so that you are clear as to what will change for CQC? It sounds from what you are saying as if you are.
James Bullion: I think we understand what is proposed. We understand that there are no proposals to change our regulations. It is simply a requirement for those organisations to be regulated and registered with CQC. An employment agency, for example, recruiting internationally to provide a bank of staff for the health service or for a social care body cannot be registered with CQC. It is not possible in law for that to happen. Our regulations are not proposed to change, so that route of international recruitment—
Q5 Chair: When you say, “Our regulations are not proposed to change,” do you know any more than what you heard in the announcement? Have you had back-channel conversations with officials since this announcement?
James Bullion: We still have more detail to work through with officials on the detail of the announcement, both on registration and on wage levels. To be clear about the run-up, we have not been formally consulted as a commission on the changes. It was clear in your last session that formal consultation was not undertaken. We have been involved in meetings to explain the broad approach, but not the specifics. The specifics remain to be done.
Q6 Chair: Did you raise any concerns in those broad discussions about the resource implications for you as an organisation, for instance?
James Bullion: Yes. We would be concerned to make sure that the implications are understood by the care sector as to what is and is not covered and what can and cannot be registered. Secondly, if that were to lead to increased registrations at CQC, we would raise a concern about our resources and our capability to respond to registration. We get about 10,000 applications for registration or variations of registrations every year. Adding more would obviously have a resource impact on us and would need to be managed. I suppose that is the further detail we would want to do with Government.
Q7 Chair: Just to be clear on what you are saying about those that cannot be registered with CQC under the current regulations—you gave the example of a company that does international recruitment into the care sector—are you saying that that is potentially an unregulated back door that could undermine the whole intention of this policy?
James Bullion: It is not unregulated, in the sense that an employment agency has a set of standards.
Q8 Chair: Sorry, let me clarify—regulated by CQC.
James Bullion: Yes. That is not registerable and is not regulated by CQC. That care work, as it were, can go on, but the international recruitment licence will not be given to those people, as we understand the proposal. That route will be closed for international recruitment.
Q9 Chair: Professor Green, you said that you were “concerned, annoyed and irritated” and “blindsided”. For full disclosure, my clerks contacted your organisation on the morning of the announcement, before I spoke in the House, because I wanted to know what contact you had had about this. I asked the permanent secretary about this last week. I asked whether Care England was consulted on the proposals prior to the announcement—or I said that they were not because we had checked with you. I asked, “Does that surprise you?”, and the permanent secretary said, “No, that doesn’t surprise me at all. That is not how immigration decisions tend to be made.”
Maybe the word, “consultation”, was the wrong word to use, because that suggests a sort of formal route. In the same way that James Bullion is saying that they were involved in informal discussions, which led to him having the knowledge that he has, were you involved in discussions around this announcement to give you the chance to say that you would be “concerned, annoyed and irritated” if this is what was announced.
Professor Green: No, I was not involved in discussions. Part of the issue is that there was perhaps not very much discussion with the Department of Health and Social Care either. We have regular contact with the Department, and we were surprised that this had not come up in our regular contact with them. To the point of whether we were consulted and engaged, or did they discuss this with us, the answer is unfortunately no.
Q10 Chair: The permanent secretary went on to say, “The Secretary of State said”—he was referring to an earlier conversation we had—“that Minister Whatley’s”—Helen Whatley, the Minister for Care—“conversations suggest that the care sector understands what we are doing, the rationale for it and how we are moving forward.” What is your view when you hear that?
Professor Green: We have all had conversations about overseas recruitment, and we have all had conversations about some of the challenges and difficulties within that. We are particularly exercised by issues such as, for example, people being exploited. There should be no place for that to happen. We have had discussions on that general level. I think the Secretary of State said in one of her announcements that we were fairly relaxed about it. I think that they have also misjudged us saying that we were happy about things such as, for example, registered providers being the people who should be engaged with this. We do not want to see a free-for-all because that is very bad not only for the sector but particularly for the people who come here.
We have had discussions about some of those things, and there were things in these announcements that we quite welcomed. Part of that was the CQC registration element, and also the issue about salary levels. If, for example, health and social care had been in the same bracket as other sectors, that would have completely killed overseas recruitment. We were, to an extent, happy about that. Our problem is that it would be really good not only to be a bit sighted on this but to be engaged in discussions. If they had engaged us in discussions, we as a sector would have been able to point out not only some of the challenges but some of the things they might be able to do to get where they want to be with their policies. Unfortunately, they did not do that.
Q11 Chair: I suppose the nub of this is whether, to get where you want to be with your policies, that is compatible with a working social care sector. The people who come here from overseas under the health and care visa have already proven themselves to be internationally mobile by the fact that they are prepared to come here. Therefore, the logic of that—to my maybe illogical mind—is that they could go elsewhere. If another country is saying, “Well, you can bring your partner, children or elderly mother with you,” and the UK is saying, “You cannot,” it seems that they might make a decision that is not in our favour. Is that fair?
Professor Green: That is very fair. In fact, only this week I discussed this with colleagues in Sri Lanka at the International Institute of Health Sciences who said exactly the same thing to me. People are now starting to think, “Is it better to go to Australia? Is it better to go to the middle east?” Of course, there is a global shortage of skilled people in the health and social care space. Inevitably, this policy will force people into making some tough decisions about where they go. We should also acknowledge that the people who come to this country to deliver health and social care are predominantly women and often have dependants. If they are faced with not being able to bring those dependants, they will make decisions and say, “Well, we cannot come.” None of us would want to leave a child or partner behind. These will be big factors in their decision making.
Q12 Chair: Oonagh, the Government’s view, as said in the House several times, is that this will not affect the pipeline of care workers. It will affect the pipeline of dependants who come with them. The Home Secretary said that he and the then Immigration Minister—now departed—have “crunched the numbers” and are confident that that is the situation. I call on them again to publish the impact assessment that sits behind that confidence. What are your thoughts on the impact of this decision on the pipeline of overseas care workers?
Oonagh Smyth: We do not know from our data set the percentage of people on health and social care visas that brought dependants, but we know from the Migration Advisory Committee’s annual report that the dependant ratio is 1:21. We cannot tell within that how many care workers who came in on the care worker visa brought dependants. We would expect it to have an impact. It is quite difficult to know the scale of that, but when we look at retention, we really need to make sure that people who have already come in on the health and care worker visa are made to feel welcome and supported. We do not know yet what the rules will be if people are already in the UK on a visa and have dependants but want to move jobs. On social care, Skills for Care describe the leaky bucket: we recruit people into social care, but we do not keep them long enough, so there is more we need to do when we look at retention.
When we take a step back and get the sense of the narrative around international recruits, we have all said in this session just how important it is to be clear that people who are recruited internationally are very welcome when they are working in social care. We need to make sure that that is how it feels—that people are supported and that they know they are doing an essential job in all our communities in a role that not only supports people to live their lives but adds quite a lot to the economy in England. All of that needs to come together so that we are welcoming people. But when we look at the broader impact, I feel like it is still not clear. We have continued to see a high number of people coming in since our report in October. Being able to understand the scale of the impact is going to be really important so that we can start to plan future capacity.
Q13 Chair: That is why we need impact assessments. We as policy makers do not work on the basis of, “Let’s try it and see what the impact is.” We have an impact assessment, which should inform policy decision making. Without that, we are blindsided ourselves.
I should just say to those shouting at the television, “Oh, he’s going on about international recruitment, but what about domestic care workers and training our own people? British jobs for British workers,” that we are not blind to that issue at all. We will come on to that as well as the pay of people in the social care sector and the impact that that has on this.
Professor Green, one of the Government’s clear arguments, which I read out in the statement, on the surcharge going up is that the dependants of care workers coming in has an impact on school places and doctors’ appointments. I am sure there is an element of that, though I would love to see it quantified, but I just wonder whether that is not the investment we make as a country—to have people who come here who are prepared to look after mum and dad when they are in a dementia care home. Let’s face it, many people would not be able to do that and would not want that caring responsibility. That is why we have a care sector that is able to do that for people who for all sorts of reasons are unable to take it on. Is it not part of the cost we have as a society to have that workforce?
Professor Green: I absolutely agree, Chair. One of our challenges is that the demographics are telling us that we will need significantly more people to work in social care in the future, and we have to have a strategy for the home-grown workforce and a recognition that we may have to recruit from overseas.
One of my concerns is that there is a lot of talk about overseas recruitment, but there is little emphasis in Government on how we are going to grow the home-grown workforce. I have to say that I want to commend Oonagh Smyth and her board, who have decided to develop a long-term strategy for the social care workforce, which is something that we have been asking the Government to do for a long time, but they consistently refuse to do it, though they do it for the NHS, of course.
We need, first, a recognition that we are going to have more need in the future and, secondly, a very clear strategic approach both to build our own workforce from the UK population and to recognise that we may have to bring in people from overseas. We need to put them into a position where they are a valued part of our system.
Q14 James Morris: Professor Green, you will have heard about or seen a “Panorama” documentary earlier in the week, which produced evidence of exploitation of overseas care workers’ contracts in a particular care home. Do you think that that is systemic across the sector?
Professor Green: I do not think it is systemic. I was very shocked by that documentary. That is exactly why we have to have a clear approach to overseas staff, because we need to be clear that they are going to be properly supported and that they are not exploited. We have to think about how we engage in a proper process of induction and also of giving information to people who come from overseas, so that they know what to expect, because we do not want to see overseas workers being exploited. They have come with their skills, they are greatly needed here, and they need to be respected and valued.
Q15 James Morris: Do you think that that particular care home is an isolated incident?
Professor Green: I think it is an isolated incident, but I do not want to underplay it. It will be happening in various places. I am also very concerned about people who might not be in services where they have other people around them. If we take somebody who came from overseas, who might be exploited, but does not have that connection with other workers—because they are working in somebody’s home, or are in an unregistered or unregulated service—that is also a great concern.
Q16 James Morris: Mr Bullion, it looks as if the evidence that was produced by the programme speaks exactly to your point about the blurred distinction between a social care organisation, which is delivering social care, and a recruitment consultancy perhaps, which is imposing fees. Same sort of question: do you think that the findings of that documentary are isolated, or does it speak to a wider challenge?
James Bullion: We were very concerned to see that programme and the evidence. In our “State of Care” report to Parliament that the CQC published in October, we highlighted our growing concern that exploitation and modern slavery were becoming a more common feature of alerts to us.
In the year before last, we made eight modern slavery referrals to the first responders; last year it was 37, or a fourfold increase; and in the year that we are in—obviously, we are still in that year, and we do not know what the figure will be at the end of the year—it is tracking at about 50 for the year. We have seen a steady growth, therefore, but I have to say that that is a small number compared with the 17,000 on modern slavery overall in 2022—the care sector is not the centre of the modern slavery world, but that is a trend and a feature of the markets now.
A few years ago, we had a market based on free movement—more free movement from Europe—but now we have a situation where people are dependent on a visa and so on an employer. The possibility for exploitation therefore increases significantly. As Martin says, I do not think that it is widespread or endemic, but I do think that it is becoming more common. We welcome steps taken and we participate every week in sharing data with UKVI, for example, to try to stem that flow, to stamp it out and to prosecute where we need to.
Q17 James Morris: Oonagh Smyth, what was your response to the evidence produced by the documentary?
Oonagh Smyth: Similar to James and Martin, the programme was extremely concerning. The exploitation of care workers and the potential for poor support for people we are supporting in social care is just not acceptable. We know there are bad actors. It is hard to know the scale of it at the minute. It is anecdotal, mostly, but we have to do what we can to prevent and detect. We also know that some poor practice comes because employers have not understood the rules; for example, a home care provider may bring somebody in from abroad and then their business reduces so they cannot give the guaranteed hours that somebody needs on a visa.
The Migration Advisory Committee points to some areas of abuse and, as James has said, there is a sense of the scale from CQC. Modern slavery and human trafficking are one. In 2022, there were 31 allegations of modern slavery via that route. We know about pay and working hours. One person in the MAC report was not paid for six months. Accommodation is another issue that we hear. The MAC report again noted a report of 39 applicants living in a five-bedroom house. There will always be stories and examples of bad actors, but again, we do not have a sense that that is systemic, although that does not mean that we should not be doing everything we can to both prevent and detect.
Q18 James Morris: Professor Green, I wanted to come round to the other thing that the documentary highlighted. Because of lack of staffing, people were not getting appropriate or timely medicines and other issues. Again, is that a systemic issue across the sector because of the shortages you identified in the initial exchanges in the session? Is it systemic that we have a situation where the workforce is in such a state of crisis that people are not getting appropriate levels of care in a safe way across the sector?
Professor Green: I do not think it is systemic. Care services are regulated by the CQC, so those issues are being constantly reviewed. What is more evident to me is the number of services that reduce the capacity they have for supporting people because they do not have the staff. So rather than support 60 people, they might only support 50 because they do not have the staff, or the specialist staff particularly. That is an area of real concern, particularly because of pressures in the NHS. We need social care to function in ways that will give capacity, because also there is increasing need out there.
Q19 James Morris: Would you describe the social care sector as being in a state of crisis?
Professor Green: I do not like to use that word. It is very dramatic. We just need a long-term and systemic view on how we are going to deliver. I think we are delivering, and I think we are delivering good quality care in the vast majority of cases. The evidence is the work that James and his colleagues do at the regulator.
What I would say is that unless we get some really clear, long-term approaches to social care, we will be in a state of crisis and that will be because there will not be the capacity to support the numbers of people who need things. I also think there is another issue, which is the number of people who could get really good benefit from social care, but because we have a system that only supports you when you go into crisis, we are constantly dealing with the people who are going into crisis. If we had the right approach, we could stop them going into crisis. That is better for them and better for the system.
Q20 James Morris: Mr Bullion, I have a specific question for you. In your state of the sector report and in relation to reports on the application of the Mental Health Act 1983, you unearthed evidence that in certain circumstances, with people who are subject to a deprivation of liberty safeguarding order, as a result of staff shortages and some issues, those orders are not being processed quickly enough. We have people in care home settings with dementia and other issues who currently do not have what we would call a legal status. They are somewhere in the middle. It is not acceptable, is it, in the 21st century, that we should have people who are not in a settled legal position in terms of the way they are going to be cared for? What can we do about that?
James Bullion: You’re right, it is not acceptable. The Commission wrote formally to the Secretary of State about that matter prior to the publication of our “State of Care” report. I am racking my memory for the actual figure: if I get this wrong, I will write to the Committee, but I think we said only about 30% or under were complied with in a timely way for the deprivation of liberty—
Q21 James Morris: Which is a shocking number, isn’t it?
James Bullion: It is a shockingly small number. It does mean that providers and local authorities who received those applications have to work together, as it were, to prioritise situations where they are particularly worried about someone’s liberty and their behaviour—so, for example, someone attempting to leave a home because of their dementia who needs to be deprived of their liberty for their own safety. You would expect those to be prioritised.
Q22 James Morris: I think it was even worse than that. I think one of your reports identified where, in certain settings, notes have been taken about a particular patient or series of patients where even the carer, as it were, was unsure about whether somebody was subject to a DoLS or not. Again, that speaks to a rather shocking risk to patient safety.
James Bullion: It does, yes. At the heart of this, I suppose, is the delay in social care reform. Over a 10-year programme we were meant to see reform in a number of areas, including the means test, as Martin has outlined, the workforce strategy and several legislative expectations around mental health—one of which is the replacement of the DoLS scheme with the liberty protection safeguard scheme, which has been delayed a number of times. Local authorities have run up the hill in preparation, only to be stood down. It is a resource-intensive change, of course, but ultimately it is about better standards of care for people and better protection of their rights in terms of their liberty. We are concerned that that remains outstanding and urge that it is pushed through as a reform as soon as possible.
Q23 James Morris: I have a final question for Oonagh, which is the same question that I asked Professor Green. Do you think the social care sector is in crisis as a result of workforce problems that you face?
Oonagh Smyth: Employers tell us all the time, and our data shows, that we have about 152,000 vacancies in social care. Capacity and gaps in the workforce impact real people’s lives—of course they do. Social care is absolutely fundamental in community infrastructure, supporting people to live their lives. Some 5% of all jobs are in adult social care and social care is fundamental to the economy. We know that there are staffing shortages in social care. The vacancy rate used to be about twice the national average, but in recent years, it has tipped to three times the national average. Staffing shortages impact on everyone. If we cannot get the people we need, with the right values, skills and behaviours, then we cannot support people to live the lives they should be living.
There is also an opportunity for us, though. We have 152,000 vacancies. That is 152,000 opportunities to work in wonderful roles where you feel valued. We need to make sure that people are valued. When we start to look longer term, our data projects what workforce we are going to need in the future. By 2035, we are going to need about an extra 440,000 people working in social care. We need to have that long-term view, because we are going to need a lot more people and we cannot get all the people we need with the right values, skills and behaviours.
That longer-term conversation that Martin referred to, which Skills for Care is supporting with the workforce strategy, is going to be incredibly important—as well as the workforce reforms that the Government announced in the White Paper in 2021, which is really about focusing on the infrastructure that we put in place. Maybe we can move on that subject. We are going to need to keep having the conversation that we are having now, about workforce reform. We will need to keep building on that for the future.
Chair: That is the perfect bridge. I know that Rachael Maskell has a number of questions, one of which is around the long-term plan for care.
Q24 Rachael Maskell: Thank you so much, Chair. Ms Smyth, may I pick up on the point you have just left and look at the challenge in recruitment and retention of the domestic workforce in the sector, which the Government are clearly looking towards? What discussions and, in particular, recent discussions have there been about remuneration of that workforce, as well as, obviously, the training and skills that are required—qualifications have also been mentioned—and terms and conditions, to ensure that there is not only recruitment, but retention of the skilled workforce?
Oonagh Smyth: I could not agree more. In social care, we often focus on recruitment, but retention is absolutely key. When we look at retention, the biggest impact is from your local labour market, or when we look at recruitment, the biggest impact is from your local labour market. When we look at retention, we lose about 390,000 people in post every year. Even though we are recruiting a lot of people in, we are also then losing them. Retention is a significant issue.
There are three things that make the most difference when we look at retention. One is quality of role. That includes pay, terms and conditions, and stability. So we have looked, in our report, at the impact of things like paying anything over the statutory minimum pension, paying anything over statutory sick pay, and zero-hours contracts. Anything that will differentiate social care roles from your local labour market will make a difference. So quality of role is really important. The other two things are learning and development, and culture and leadership. They are the three things that we really need to focus on.
The White Paper reforms, putting “People at the Heart of Care”, are really sensible reforms—evidence based and focusing on the learning and development element. That should help people to be able to see a long-term career in social care. This should help with recruitment, but it will also help with retention, because we know that if you train somebody, they stay, and the more you train them, the longer they are likely to stay. And we have seen launched some of those initiatives, like the care workforce pathway, to give some of those clearer career pathways.
We are going to need to look at the other two elements—the quality of role, in relation to terms and conditions, and culture and leadership—if we want to recruit more people and to keep them. About 16% of providers have a turnover of less than 11%, and when we ask those providers with the lowest turnover, “Well, what is it that you do?”, they tell us that it’s about culture; it’s about saying thank you. Really importantly, it’s about living your values. And it’s about the organisational leadership. As well as looking at terms and conditions, we really need to be looking at culture and leadership in organisations. A lot of organisations do this really well, but that is going to be key if we want to recruit more people and to keep them. We recruit more people every year than the whole population of Bristol—we recruit quite a lot of people. We really have to focus on making sure that we can support them and keep them.
Q25 Rachael Maskell: May I come back to you? Obviously there is a fiscal reality behind this, in the light of there being currently no long-term workforce plan for social care from the Government. That presumably means there are no discussions with the Treasury either; certainly we have not heard that from the Chancellor.
What discussions have taken place about the remuneration element in the light of cost of living challenges, but also the fact that social care has fallen behind in the labour market? Local authorities and ICBs are currently clearly grappling with very difficult budgeting, so what real discussions have taken place on the realities of social care workforce pay, not least because we know that there is a labour shortage across the whole of the economy—in, I think, all bar about one or two sectors?
Oonagh Smyth: At Skills for Care we think about pay a lot, as you would expect. There are really three elements.
There is the element of competition in the broader labour market, which will depend on the local context, but that is incredibly important. When we start to see vacancy rates go down in the wider labour market, as we are seeing now, we would expect to see people coming into social care, because of that local labour market.
We also know that when people come into social care, they are more likely to come in from retail or hospitality, but when they leave, they are more likely to leave for another caring profession, like health, so pay differentials between social care and health become even more important in that context. The Skills for Care analysis shows that a healthcare assistant will get, on average, £1 an hour more than somebody starting in social care, and that goes up to about £1.60 an hour within 18 months. Differentials between sectors become really important.
When we look at pay differentials within social care, there is about a 6p difference between the most and the least experienced care worker. I could start in social care today and I would get about 6p an hour less than somebody who might have been in social care for five, 10 or 15 years. Those differentials have squeezed over the years—in March 2016, that difference was 33p an hour. So we need to look at a number of elements in terms of pay, depending on whether we want to focus on recruitment or retention, because we might take a slightly different approach, but we do know that pay makes an impact.
Pay is not the only thing that makes an impact. We really do need to make sure that when people start in social care roles they understand the potential for development, feel valued and feel like they are listened to and have some autonomy in the role. There is a whole range of things that we need to do, which is why a joined-up workforce strategy is so incredibly important.
Q26 Rachael Maskell: Professor Green, one thing we have not seen is an impact assessment from the Government. Are you producing your own impact assessment in the light of what the Government have announced?
Professor Green: No, we are not. This is something that the Government need to do—they are required to do impact assessments—and we could not do it as comprehensively as they would. What we will do is try to find out from our members what the impacts will be. I wouldn’t like to say it would be a comprehensive impact assessment, but it would give people an understanding of how the changes might impact on the care sector.
Q27 Rachael Maskell: From your own analysis, what is your understanding of the capacity to expand the domestic workforce versus the international workforce?
Professor Green: Oonagh eloquently identified this. We have to have a long-term strategy. If the Government’s policy is to say, “We want to grow the home-grown workforce,” they need to have a really clear strategy on it. We need to see some really clear skills and competency frameworks. We need to see portable qualifications. We need to see career pathways, and often they will move between health and care, just as citizens do. We need to see, as Oonagh said, the issue around differentials taken really seriously, because the development of people who have skills needs to be rewarded properly. I would like to see this become really clearly a career, not a job. I do not think there is any place for the minimum wage in the sector. Caring is very complex and very challenging, but it is also very rewarding. We have to reassess how we think of the social care workforce.
I also think that the quality of work is really important—Oonagh made that point. One of the things that we need to understand is that people want to work in different ways. As a sector, we need to think about fishing in different pots. For example, there are lots of early-retired people who could make a great contribution to our sector, but they do not want to work either full time or, indeed, for 17.5 hours a week. They might, though, be prepared to work and support care services, so we have to think differently about how we structure the whole role. We have also seen, because of covid, how people work in very different ways. Lots of us have the glorious flexibility of doing some work from home and some work in the office; that is not available if you are doing frontline care work. We have to think about how we enable people to have a better quality of work.
I also think that the point Oonagh made about career pathways is really important. We need people to understand that you can have a successful career in social care. From my own point of view, I have been very bad at making sure that those messages get out. Something we will do much more effectively in the future is identify where people can make successful careers in social care and get a lot out of it, but we will also need the remuneration, recognition and professionalisation to come alongside that important work.
Q28 Rachael Maskell: Ms Smyth and you have listed a range of significant changes that need to be brought in to build sustainability behind the workforce. The Government plan to bring in their new scheme for overseas recruitment in the spring. What is your message to Government on their timing of that announcement? What are the implications that it will have in the nearer future, as well as the longer-term future?
Professor Green: The timing is unfortunate, because what the Government do not have is a clear strategy on how they will grow the home-grown workforce. They have said that they want to have much more of a home-grown workforce, but there is no strategy for that, although Oonagh and her colleagues will be developing one. I would like the Government to have brought things in when they had a clear strategy, so that we could know that we were transitioning from one level of plugging the gap to another.
The other thing that people need to be clear about—Oonagh has said this—is that the number of vacancies in this sector is huge, so we will have to grow the home-grown workforce and recognise that we need people from overseas. There needs to be a comprehensive approach to planning that. It needs to include the home-grown workforce, how we bring in the right people from overseas, and how they get good-quality jobs.
Q29 Rachael Maskell: Mr Bullion, can I turn to you on regulation? Thank you for your earlier comments about its complexity and your scope to bring in any adaptability. Over recent years, clearly there have been some failures in the scope of regulation for people outside the remit of the CQC. The Government have stated that that is the rationale for introducing many of these changes. How do you believe that that gap in regulation can be closed in time for the spring, when the Government plan to introduce the overseas recruitment changes?
James Bullion: At present, there are no proposals to change our regulations on what is regulated activity or on registered organisations. We have no such proposals. There are separate discussions on the role of supported living and on bringing those regulations into our scope, which is welcome. I do not think that at the moment there is any prospect of any change to our approach by the spring.
It is clear to us as a regulator that, unless we are very specific about what is and is not covered, those organisations are recruiting PAs for people or live-in carers will need to take steps between now and the spring to make sure that any continuity-of-care issues are picked up, whether by local authorities, or by the caring organisations or caring situations around that person. We have a concern to get clarity and, where we see gaps, to make sure that those gaps are addressed through care continuity arrangements.
In the commission, we do not feel that the answer is more regulation. This is a proposal to say that those who are not regulated cannot use this route. Those people therefore cannot be recruited in that way. As Oonagh and Martin have said, that means that the domestic workforce has to step in. Our concern is that the social care workforce grew by just 1% in the past year, and most of that was international recruitment. That is what it seems to us from the Skills for Care report and our own “State of Care” report.
We will now see that workforce shrink, unless we have a compensatory step to expand the domestic workforce, which will come not from regulation but from employment incentives or the workforce strategy that Martin and Oonagh outlined. I see no prospect of regulation being the answer to the workforce problem. It is an answer to make sure that those organisations that are in our sphere are properly managed, so we minimise exploitation and so on. That is a positive, but it will not answer the workforce question.
Q30 Rachael Maskell: I just want to pick up on that point. Clearly, you are identifying a risk for people who receive direct payments for their personalised care, and as a result you are fishing from a small pool with regard to being able to expand the workforce, if indeed that is the pattern as opposed to it contracting. If it does reduce, because of retention issues but also recruitment issues because of the measures the Government are introducing, that is clearly going to introduce new risks or expanded risks into the sector. How are you preparing organisations to accommodate those risks so that they do not fall short in the other statutory requirements that they have in order to provide safe services? That clearly has to be done before the spring as well.
James Bullion: The commission would be a blunt lever in trying to prepare the sector for this change. I think it is more likely that work with local authorities would need to be in place to respond to this kind of change.
We do now have a role, as a regulator, to look at adult social care and to assure, on behalf of Government, local authorities. We have just completed pilots in five local authorities and are now rolling out that programme over the next two years, where we can look at councils, how well they commission and how they work with their market to shape sufficiency. That is at a very early stage, and of course that will not happen by the spring, so it is going to be really important, as I said, that the detail of how this will work is worked up as quickly as possible, so that individuals who are affected by it, with existing PAs or live-in carers, know what to do, and then local authorities and local health services can anticipate the impact of recruitment on their future demand. We wouldn’t seek any bringing in of new regulation of things like personal assistants, because there is a long tradition of people being able to employ their own carer and having the independence to do that. That is currently not regulated, and we don’t have a view that it should be.
Q31 Rachael Maskell: May I just pick up on the issue of your timelines, with regard to looking at the change that you are talking about and how long you are expecting that piece of work to take?
James Bullion: We have a baselining period, about which we are still in discussions with the DHSC, about rolling out assurance for local authorities and, indeed, for integrated care systems. So those systems reviews are now under way. It’s at least a couple of years to get that rolled out and baselined before we then can rate, as it were, all 153 local authorities.
Rachael Maskell: Thank you ever so much. I certainly have heard from all three witnesses that spring is a very premature date to be able to provide the safety that is required and the workforce who are required, but also the social care.
Q32 Chair: To continue that theme, what we are coming to is that on timing, which Professor Green said was unfortunate, this may be a case of right idea, wrong time.
I said we would return to the issue of domestic labour, which we have touched on with my colleagues, because there is the argument that we are just hooked on the drug of imported cheap labour. The Government have said that domestic workers could be better utilised to fill these vacancies, and the factsheet from the Home Office that was published on 4 December says that “to ensure that the labour market prioritises UK residents when filling vacancies…The Government is encouraging all sectors to adapt and make employment more attractive to UK domestic workers through offering training, career options, wage increases and to invest in increased automation technology.”
I am not quite sure what that means, but let me go back to what Care England and Skills for Care said in their submissions to our workforce inquiry. Care England talked about how “low rates of pay and lack of benefits and reward for social care” are “driving…staff to leave the sector. Competing sectors are able to offer higher rates of pay for fewer hours and less emotionally challenging work”, which I suppose continues to be true in an economy where there is a falling number of vacancies, because there are obviously other attractive options. The old adage is that people can earn more in Tesco than working in a care home.
Professor Green, could I return to the transcript from our meeting last week with the Secretary of State and the permanent secretary? The permanent secretary said to me: “It is important to remember that we are heavily over-subscribed. The limit on the number of people who are coming into the country is the number of jobs available, not the supply of international labour.” I am struggling with that, because we have quite a lot of jobs available. Last time, the House of Commons Library told me that there were 151,000 vacancies in the care sector in England. Can you make sense of that?
Professor Green: No. Clearly the permanent secretary has not seen the data that is produced by Skills for Care, because there are significant labour shortages in our sector. Also, I think there is a view, certainly from that comment, that anybody can do this work. Quite clearly, it requires people who have the right values, as well as the right skills. We have got a major problem in terms of recruitment and retention in our sector. The data is there—Oonagh Smyth and her colleagues at Skills for Care deliver it; James and his colleagues at the Care Quality Commission deliver it—so I am at a loss to know on what data that answer was based.
Q33 Chair: If we look at the impact of these changes on people who require care, should they go ahead in the spring as proposed—of course, there could be a change of heart, or a change of Government, though I am not entirely sure that the Opposition has committed to changing this—what do you expect to be the immediate and long-term impacts of these measures on people who need care? What are the consequences of the increase in people providing unpaid care, given that if the number of vacancies stays at 151,000 or increases, there is going to be an impact both on people who need care and on people who are providing unpaid care?
I mentioned earlier people who either do not want or are unable to care for ailing relatives, but many people do that, despite the fact that it is putting a huge pressure on their mental and physical health and their ability to then be in the workplace themselves. What is the impact going to be on people needing care? That is the human story here, isn’t it?
Professor Green: Absolutely, and the impact will be enormous. What we will see is that there will be less care available and people will be at higher levels of dependency when they access it. You will also have the enormous pressure on unpaid carers and family members, some of whom will not be able to cope with that pressure and will then become people who need care and support themselves, whether that is mental health support or whatever. There needs to be a clear and strategic approach to the workforce in social care. These changes seem to have come out of the ether and are not necessarily driven in a strategic way.
There is also little discussion about the role of integrated care systems and their workforce strategies within local areas. If we had confidence that they were going to do things locally, perhaps there would be a reason why the national picture was ignoring this. The bottom line, though, is that we have really significant staff shortages; we have an increasing need for care, which is only going to get worse; and we have to think creatively about how we attract people into the workforce. Perhaps we also need to think differently about we use technology, for example, to enable people to focus on the really important work of caring and to take some of the administrative burdens away from them.
Q34 Chair: I said right at the beginning that the changes were part of the plans to cut net migration by 300,000. Would it be fair to characterise your concern as being that this is coming from the top headline figures, not from the bottom up with what the sector says it needs?
Professor Green: Yes. My view is that we need to look at this in terms of what the sector needs. We will always need some form of migration into this sector. If we want a clear approach to how we grow our own workforce, we need to think about where the gaps are and how we fill them. It seems to me that this policy has been driven by something completely outside the issue of health and social care. It has been driven by challenges around migration, with little recognition of the impact that it is going to have. It is a classic case of a policy driven by a headline, not by a need.
Q35 Chair: Oonagh, surely one of the most concerning things that we heard this morning was when Professor Green said that he thinks that there has been very little involvement from the Department of Health and Social Care.
Oonagh Smyth: Skills for Care is a member of the international recruitment steering group with DHSC, and we have been speaking about international recruitment in adult social care a lot; Martin and James have both covered that.
On the concerns about reports of exploitation and how international recruitment was working in social care in practice, we had a lot of conversations around the mechanism, and the specific changes were not clear to us. To pick up the point about the impact on the domestic workforce, our data shows no evidence that international recruitment is preventing the domestic workforce from taking roles in social care. There are still quite a lot of roles in social care. With 70,000 international recruits and an increase of 20,000 in the workforce, we still have a number of vacancies, although those vacancies have continued to reduce since we published our report. We would know if international recruitment was affecting domestic recruitment if we were seeing much lower vacancy rates and evidence of domestic recruitment becoming easier.
I did want to pick up the point that this is not just about numbers; we need the right people with the right values. Forcing people to work in a job that they do not want to do in our sector, given what we do, is not something that any of us wants. We really do all want social care to be a career of choice, not a career of last resort. We really need to think about people who want to do the role, can do it well and can provide support that allows us the stability to be able to build relationships with the people that we are supporting. These are incredibly skilled roles, so numbers are important to think about, but it is also about getting the right people. They are too important.
Chair: I think that is a good place to conclude, unless anyone has any other platforms that they have a burning wish to speak about.
Oonagh Smyth from Skills for Care, James Bullion from the Care Quality Commission and Professor Green from Care England, thank you very much for coming in at relatively short notice to give us your views. I ask that you keep us updated as you talk to your sector. From your conversations with Rachael Maskell, I know that you are not doing an impact assessment, but you are understanding the impact. If you keep us updated in correspondence, which we will then publish as formal correspondence, that will help us to build up the evidence base that we are collecting. I wish you all a very merry Christmas with your families, and I thank you for coming in.