Written evidence submitted by UNISON (WBR0027)

Executive summary

• Pre-pandemic research and surveys show NHS staff under pressure in a number of areas.
• The problems for the workforce were even more pronounced in social care.
• Surveys of UNISON members during the pandemic point to problems with work/life balance for healthcare workers and a lack of faith in risk assessment processes for Black workers.
• NHS staff must continue to have access to Covid special leave to limit the spread of the virus.
• Too few care workers are getting the sick pay they were promised, and testing is inadequate.
• Health and care staff remain under increased pressure as they continue to meet the extra demands on them during the pandemic, and many will need mental health support afterwards.
• There have been some positive developments for healthcare workers during the pandemic, such as the increasing use of flexible and remote working.
• Concerted action is needed to address workforce shortages in the NHS and social care.
• The failure to include care workers in the plans for a post-Brexit fast-track visa system for healthcare workers will have a further damaging effect on the care sector.
• As the NHS looks to get services back on track, while continuing to observe social distancing rules, there will be a need for more staff.
• The new ways of working outlined in the People Plan and NHS Long Term Plan will require more staff to manage change and moves to new models of care or different ways of working.
• The NHS and social care should plan for the possibility that staff sickness levels will remain high for months after the pandemic has passed.
• UNISON is calling for tuition fees for healthcare students in England to be scrapped and living maintenance grants introduced that reflect actual student need.
• The new package for nursing degree apprenticeships is welcome, but this approach should be extended beyond nursing and apprentices need to receive a fair and consistent wage.
• As highlighted by the pandemic, the status of care workers needs to be raised and a crucial part of this is to end the perception that care work is “unskilled”.
• The plans for flexible working, wellbeing and tackling violence in the People Plan are all positive, as is the acknowledgement that systemic racism continues to blight the NHS.
• But the People Plan misses an opportunity to link into the key area of staff pay and reward, and it is powerless to effect real change in social care.
• The Plan is light on how its ambitions should be put into practice and until the government commits funding it will be impossible to address issues such as the numbers of staff needed.
• Accompanying plans to “bust bureaucracy” appear to have mistakenly conflated management and bureaucracy, despite the NHS being relatively under-managed.
• The government should aim to address the imbalance between the health and social care workforces by seeking to level up in areas such as pay and training.
• In social care the lack of central levers available to ministers – compared to the NHS – has been exposed by the pandemic, as has the lack of social partnership machinery.
• The health trade unions’ “Blueprint for Return” contains several measures directly relevant to tackling workforce stress and burnout in the short term.
• The government and regulators must find a way to compel care providers to pass on Infection Control Fund money to care workers so they are not left out of pocket when they self-isolate.
• Steps need to be put in place to ensure that all care workers are tested each week. 
• UNISON has set out a series of relevant measures in social care, including an end to poverty pay and standardised employment procedures; an expanded and mandatory Care Certificate; registration of care workers; a workforce strategy; and NHS-style “social partnership” working.

About UNISON

1. UNISON is the UK’s largest union, with more than 1.3 million members providing public services – in the NHS, local government, education, the police service and energy. They are employed in the public, private and voluntary sectors.

Introduction

2. Thousands of UNISON members in a variety of sectors have been on the frontline in dealing with the response to the Covid-19 pandemic.  Wherever possible the union is working alongside governments, the NHS, councils and others to play a part in containing the spread of the infection and mitigating its effects. This submission is divided into sections based on the key areas of the inquiry’s terms of reference. UNISON would welcome the opportunity to give oral evidence.

Workforce resilience, stress and burnout before Covid-19  

3. The most recent NHS staff survey (released in February 2020) highlights several areas where the resilience of the NHS workforce is being sorely tested. For example, 40% of staff reported feeling unwell as a result of work-related stress in the past year (a proportion which has been rising steadily since 2016); more than half (56%) of NHS staff came to work despite not feeling well enough to be there; while the same percentage of staff reported working extra unpaid hours on a weekly basis, a figure that was even higher for those working in community services, mental health and learning disabilities.[1]

4. Research carried out before the pandemic by the Society of Occupational Medicine reveals a workforce already under considerable pressure before the additional challenges of dealing with Covid-19. This suggested that a new workplace culture was needed that “explicitly recognises” how the very nature of the work carried out by nurses and midwives can strain their mental health. It called for action to tackle the “organisational causes” of stress that increase the burden on staff, such as high workload, poor leadership and bullying.[2]

5. In early March 2020, just prior to the lockdown, UNISON hosted a large Safe Staffing Forum to hear from nurses, midwives, healthcare assistants, allied health professionals and healthcare students about workforce shortages and safe staffing.[3] The event highlighted worrying fears about insufficient staffing levels to keep patients safe, along with a number of survey findings about the impact this had on staff themselves. For example, two-thirds of attendees (65%) did not believe that staffing levels were sufficient to allow them to take adequate breaks and leave work on time; while a similar proportion (63%) reported that staffing levels contributed to anxiety and high amounts of stress for them. Anecdotally, attendees reported that the health implications they faced included dehydration, poor diet, anxiety, stress, guilt, low morale and negative effects on their family relationships.

6. Each year UNISON carries out a snapshot survey of healthcare members to gauge their experience at work on a given day. The most recent (2019) edition of the survey revealed that unsafe staffing and lack of support is not just a major issue in terms of patient safety, but also a serious problem for staff wellbeing: 47% of those responding reported being unable to take their allocated breaks and one in six could not take any break at all on their shift; 38% did unpaid work over their scheduled hours; and 68% reported significant stress at work.[4]

7. Feedback from members of UNISON’s student nurses’ network shows the problems for those preparing to enter the NHS workforce. Since the abolition of the NHS bursary, nursing students report having to take on second jobs to make ends meet on top of their demanding degree courses. This leads many to suffer from burn-out in their third years and to drop out or require an extended break before they feel able to join the full NMC register.

8. The problems for the social care workforce are in many ways even more pronounced. The basic instability and uncertainty of working life for so many in social care show why it has the potential to be such a high-stress sector to work in. Prior to the pandemic, across the sector a quarter of care workers were employed on zero-hours contracts, a figure that was even higher for those delivering homecare.[5] More than half of care workers earn less than the real living wage set by the Living Wage Foundation, and thousands still do not even receive the lower National Minimum Wage[6]  – largely due to the failure of employers to pay staff properly for travel time in homecare and “sleep-in” shifts in care homes.

9. These problems and the wider lack of status afforded the sector have combined to fuel staff turnover: before the pandemic more than 30% of care workers were leaving their jobs each year, equivalent to 440,000 workers. Social care also went into the pandemic with a high vacancy rate of nearly 8%, equivalent to around 122,000 vacancies at any given time.[7]

10. A survey of UNISON members working in social care conducted before the pandemic shows how intolerable working conditions have been pushing care workers to the brink over recent years. Nearly half (49%) were thinking of leaving their job, with low pay given by those who responded as the main reason (73%), followed by not having enough time to deliver care (53%). More than half (55%) did not feel respected and valued by their employer, and 41% said they were not treated fairly at work.[8]

The impact of Covid-19

11. UNISON surveyed the union’s healthcare membership in June 2020 to ascertain a picture of working life during the pandemic. The survey received around 20,000 responses and many of the results are directly relevant to this inquiry. For example, 29% of all those surveyed said they did not feel able to work without worrying about their caring responsibilities, a quarter (25%) did not feel able to take annual leave when they needed to, and nearly a third (30%) did not feel able to have rest breaks with adequate facilities when they needed them. For those who identified as Black, Asian or minority ethnic, less than half (49%) said their employer or manager had spoken to them about having an individual risk assessment, less than a third (31%) felt their employer was doing enough to address all the risk factors they are facing, and only 38% felt they could safely discuss their concerns about racial and ethnic disparities when it came to the risk from Covid-19 at work.

12. There are also reports about the impact of the pandemic on particular sections of the healthcare workforce and some parts of the sector. For example, nearly a quarter of NHS managers have been working more than 20 hours a week in unpaid overtime during the pandemic.[9] And there are warnings that, without additional staff, the mental health workforce will be at even greater risk of burnout and high attrition rates as a result of the pandemic.[10]

13. Partnership working in the NHS produced an early positive step in managing the pandemic when the decision was taken to remove the penalties of illness from staff. The early implementation of Covid special leave for NHS staff was a key measure in limiting the spread of the virus. It ensured that loss of earnings was not a barrier to compliance with infection control measures and that staff getting ill as a result of their work were supported. It is important that staff continue to have access to Covid special leave: not only are localised spikes in infection rates likely over the coming months, but more is now known about higher risk categories and about the long recovery period many people face. In order to support all staff to continue or return to work, the expectation must be made clear that the NHS will not penalise those who have to change the way they work due to the risks or impact of Covid-19. Not only will this ensure that staff do not experience financial penalties because of their exposure or potential exposure to the virus, it will also help to minimise the risk of infection between staff and from staff to patients/visitors during the crucial months ahead.

14. The experience for those working in social care during the pandemic has often been deeply traumatic. Despite the creation of the Infection Control Fund, a UNISON survey of care workers (conducted in July 2020) shows that still far too few care workers are getting the proper sick pay they were promised. More than half (52%) say their employer is still paying less than £100 a week or nothing at all if they need to shield or self-isolate. In addition, one in nine care staff (11.5%) say they are still not getting the essential personal protective equipment they need in order to do their jobs safely; almost half (48%) said they have never been tested for Covd-19, despite repeated government pledges about care sector staff being monitored regularly; and less than a quarter (24%) of all the respondents had been tested more than once since the beginning of the pandemic, and half of these had been tested just twice.[11]  

15. Health and care staff remain under increased pressure as they continue to meet the extra demands on them during the pandemic. As a result, many workers are likely to need mental health support after the pandemic, with nursing academics fearing an exodus of traumatised staff after the crisis.[12] Charities offering support to healthcare workers have highlighted increased stress and anxiety in the workforce, with some presenting more serious conditions such as post-traumatic stress disorder (PTSD). Factors such as lack of equipment, staff shortages, redeployment and the death of colleagues have been added to more obvious anxieties about the health risks that NHS workers face themselves.[13]

16. There have been some positive developments for healthcare workers during the pandemic. For example, the use of flexible and remote working has increased significantly.[14] As highlighted in the recently published People Plan, “many colleagues across the NHS have noted that this has been more productive, with less time spent travelling (with the additional benefit of reduced air pollution), and better turnout at meetings, as well as improved work–life balance”.[15] Some trusts have also taken steps to create designated areas for healthcare staff who need space to recuperate during crisis – “wobble rooms” allow staff a quiet place to go when they are feeling overwhelmed at work.[16]

Projections for the future workforce

17. Concerted action will be required to address current workforce shortages in the NHS which are projected to worsen over the next decade. The NHS entered the pandemic afflicted by major shortages, with nearly 100,000 overall vacancies, including nearly 40,000 in nursing and over 2,000 in midwifery.[17] In the run-up to the 2019 general election, health think tanks predicted that such shortages could grow to 200,000 by 2023/24 and to at least 250,000 by 2030, with nursing shortages remaining particularly problematic (potentially over 100,000 by 2028/29).[18]

18. Social care also has an even bigger problem with staff shortages, with 122,000 before the pandemic.[19] The failure to include care workers in the plans for a post-Brexit fast-track visa system for healthcare workers will have a further damaging effect on recruitment in a sector where nearly 17% of the workforce are non-British nationals.[20]

19. There has been a welcome recent increase in nurses and midwives on the NMC register. However, almost half of this increase is a result of international recruitment of nurses from outside the EU, particularly from the Philippines and India.[21] Unfortunately, since these figures were collated this route has been significantly disrupted by the pandemic and the travel restrictions that have been in place since April.

20. As the NHS looks to get services back on track, while continuing to observe social distancing rules, there will be a need for more staff. The additional capacity created by recent positive developments such as the use of retired returners and paid student placements may be required to boost staffing numbers in the recovery period and potentially further into the future.

21. In the longer term, the new ways of working outlined in the People Plan – and previously the NHS Long Term Plan – will require more staff to be available to manage change and oversee the transition to new models of care or different ways of working.

22. The NHS and social care should also plan for the possibility that staff sickness levels will remain high for months after the pandemic has passed, with previous experience showing that the effects of stress or PTSD from working through such a traumatic period do not necessarily manifest immediately in the health and wellbeing of staff. UNISON is seeking negotiations with NHS employers to look at new ways of approaching this in terms of sick pay, for example with sick pay available for longer and with longer phased returns to work after sickness absence.

Training and apprenticeships

23. Attracting enough new entrants into nursing, midwifery and the allied health professions is a significant challenge. Demand for services has grown over the past five years and yet, despite recent improvements, the numbers applying to study nursing in particular have still not recovered to 2016 levels, before the NHS bursary was scrapped and tuition fees introduced for healthcare students in England. Many prospective healthcare professionals have been deterred from studying at university due to the prospect of debt.

24. The government announced in December 2019 that maintenance grants will be reintroduced for healthcare students in England from September 2020, but these are only half what students in Scotland are set to receive and tuition fees will still have to be paid. In addition, those students who started their courses in Spring will not be able to receive the grants until the beginning of their next academic year in Spring 2021.[22] UNISON, along with other unions, is calling for tuition fees for healthcare students in England to be scrapped and living maintenance grants introduced that reflect actual student need.

25. UNISON welcomed the recent announcement of a new funding package for nursing degree apprenticeships. The union has long been championing the need for employers to be able to use apprenticeship funding to cover the costs of “backfill” staff while apprentices are undertaking education and training. Properly funded apprenticeships are a way of attracting new recruits to nursing at a time when traditional routes in have become less attractive due to the continuation of tuition fees. Apprenticeships can also open new career pathways for existing NHS staff. It was frustrating, however, that this announcement was limited to nursing – UNISON would like to see apprenticeship routes prioritised for other healthcare professions where shortages exist. And there remains a need to ensure that apprentices receive a fair and consistent wage; until this is resolved the NHS will struggle to attract enough apprentices.

26. In social care, the pandemic has led to care workers effectively being redefined as key workers. But rather than a temporary reclassification, this elevated status must become an enduring feature of the sector – with a corresponding improvement in pay and conditions. A crucial part of retaining this higher standing for care work is to end the perception that it is “unskilled”. Much of the work that care staff carry out requires considerable technical skills and inter-personal abilities that are often overlooked.

27. Many care workers also have a frustrated desire to undertake greater training and development opportunities, which are virtually non-existent for large swathes of the workforce, some of whom receive very little training before they begin work. This applies at all levels, with many care managers taking on their jobs without any training. During the pandemic care workers have been expected to carry out important Covid-19 swab tests on residents and fellow workers, but the training is just an online video and some written guidance. The Care Certificate only covers a basic induction into care rather than more specialised training, and it is not a mandatory requirement for employers, contributing to the inconsistency across the sector. And England has yet to follow other parts of the UK where there is professional registration for care workers – one way of at least ensuring a more consistent approach to standards and boosting the prestige of care work.

The NHS People Plan

28. The recently published People Plan rightly acknowledges the severe strain that Covid-19 has placed on the healthcare workforce, as well as the commitment and sacrifice of NHS staff in continuing to deliver for patients during this time. And while there is little new in the plan, there is an important recognition that some of the positive changes brought about by the pandemic should become part of the everyday experience of working life in the NHS. The plans to ensure greater flexible working are positive, particularly as the NHS Staff Council will have a role in ensuring they become a reality. Likewise, the continuing work to tackle violence against NHS staff, as well as the practical steps to improve and protect staff wellbeing.

29. The acknowledgement that systemic racism continues to blight the NHS is welcome, as are the detailed plans to address discrimination. The work of UNISON’s “Race for Equality” campaign would suggest that priority areas for this part of the Plan should include recruitment and selection, disciplinary processes, and career progression.[23] An important first step should be to ensure there is proper action taken to understand, assess and act on the risks identified to Black NHS staff from Covid-19. And the sharing and publication of this data across the NHS in England would give much-needed confidence in the actions taken so far to protect Black staff.

30. On the downside, there is a major missed opportunity when it comes to pay, with a failure to link any of the People Plan aims to staff reward. Many of the ambitions outlined in the Plan to improve staff morale or boost recruitment and retention are inextricably tied to levels of pay, so this feels like an obvious gap. Similarly, while there are a number of references to the importance of the NHS working with social care, the Plan is powerless to deliver real change in this area while the government continues to duck the pressing need for wholesale reform of the social care sector.

31. As part of accompanying plans to “bust bureaucracy”, the government seems to have wrongly conflated management and bureaucracy[24], which represents either an unfortunate ignorance of the fact that the NHS has traditionally been relatively under-managed compared to other sectors[25], or a lurch into populism.

32. The Plan is light on how its various ambitions should be put into practice. All health systems are expected to develop their own local people plans to detail how they will implement the aims of the national plan, but this puts a great deal of responsibility onto the emerging systems, some of which will be in a better position to do this than others. UNISON would expect to see NHS Social Partnership Forum structures used as a way of driving activity to help turn the aims of the People Plan into tangible improvements for staff and services.

33. There remains the perennial problem of funding the laudable plans outlined in the Plan. Crucial elements of any effort to properly address key workforce issues – such as the actual numbers of staff needed to make up the future NHS – remain on hold pending government funding allocations. For this the NHS must wait until later in the year at the earliest, and this assumes that Covid-19, Brexit or other unforeseen problems do not blow the spending review off course. There are clearly many extenuating circumstances, but in an ideal world the NHS would have a fully funded comprehensive workforce strategy for the next five years, rather than a stop-gap solution for the next nine months with very little money attached.

Parity for the social care workforce

34. Addressing the imbalance between the health and social care workforces should be a priority for the government – in terms of fostering greater integration between the sectors, but also bringing areas such as pay and training in social care up to comparable levels with the NHS. This should ideally be part of a wider drive to raise the overall status of care work within society, because a key lesson of the pandemic is that social care must never again be viewed as the poor relation of the NHS.

35. In social care the lack of central levers available to ministers has been exposed by the current crisis. Though staff testing and the distribution of PPE has been far from perfect in the NHS, there are at least ways for the centre to effect change in hospitals and other healthcare settings, which can benefit staff. The more disparate nature of many social care services (particularly in domiciliary care) is one reason why this is harder to replicate in social care, but so too is the hugely fragmented care market in which around 18,200 organisations are involved in providing care across nearly 38,000 establishments in England.[26] Compared to the NHS, this has made it harder, for example, for government and councils to target and reach all the care workers they need to get tested.

36. These problems are compounded by the lack of one obvious representative body for care employers and, while there is well-established partnership working in the NHS, this does not exist in any formal way in social care. The extensive work of the NHS Social Partnership Forum on important issues for staff – such as terms and conditions, and health and wellbeing – allowed the system to intervene relatively quickly during the pandemic to offer guidance to employers and some degree of reassurance to staff.

Further measures required

37. The health trade unions came together in May 2020 to produce the “Blueprint for Return”, which outlined nine asks of government and employers to help staff and patients stay safe as lockdown was being eased. A number of these are directly relevant to tackling workforce stress and burnout in the short term, specifically the need to ensure there is enough suitable protective equipment available; the need for proper risk assessments for all staff; the need for unlimited access to testing with rapid results; and the need to ensure that staff get a proper work/life balance – by recording and controlling excess hours, reviewing long and rotating shifts, enforcing working time regulations and encouraging staff to take rest breaks and annual leave.[27]

38. After the pandemic there will also need to be particular support for the workforce on skills. This will need to include reskilling staff that have been redeployed or had their usual work cancelled for long periods. The potential otherwise is for this to affect the morale or status of staff, many of whom have found themselves working in unfamiliar ways during the pandemic.

39. In social care, in the short term the government and regulators must find a way to compel care providers to pass on Infection Control Fund (ICF) money to care workers so that they are not left out of pocket when they need to self-isolate. Councils should be told to ask for proof that the money they pass on to employers through the ICF is reaching eligible care workers, with employers that do not pass on this money subject to penalties. 

40. Steps also need to be put in place to ensure that all care workers are tested each week. Currently too many employers are carrying out weekly tests on a set day and only testing the staff who happen to be on shift that day, meaning that up to half of all care workers are not being tested each week. ICF money can be used to ensure staff who are not working on a particular day can be paid for their time to travel in and get tested, or alternatively employers should take steps to have a rolling approach to the testing of staff so that everyone gets a test per week. The concerns above about the ICF not reaching eligible care workers mean that some care workers are being deterred from getting tested in case they test positive and then face the prospect of going without work and pay for two weeks – another reason why the flaws in the implementation of the ICF need to be addressed urgently. As well as covering regular family visitors to care homes, UNISON members who work at the CQC have requested that testing should also be extended to CQC inspectors.

41. Beyond this, UNISON has set out a series of measures that would help to build the resilience and morale of care workers in a recent document on the future of social care.[28] These include dedicated investment in the workforce to end poverty pay and standardise employment procedures; the Care Certificate should be expanded to cover the technical skills required of care workers and should become mandatory; there should be a new focus on continuing professional development and a ladder of qualifications to aid career progression; place-based care systems should be used to join up recruitment, induction, training and development provision for both health and care staff, including higher-level apprenticeship programmes; registration of care workers is necessary to ensure care work is perceived as a professional occupation rather than dismissed as “unskilled”; there needs to be a comprehensive workforce strategy for social care to counter the recruitment and retention crisis that blights the sector and to help establish care work as an attractive career choice; care workers should be prioritised alongside healthcare staff in government immigration policies; and there is a need for an NHS-style “social partnership” approach in social care to bring together commissioners, providers, governments and trade unions to devise solutions to the well-known problems in the sector.

Submission produced by the UNISON Policy Unit.

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