Written evidence submitted by GMB Union (WBR0066)

GMB welcomes the opportunity to submit evidence to the Health & Social Care Select Committee inquiry which is examining workforce burnout across the NHS and social care. The increased pressures brought on by Covid-19 and the resilience of the services to cope with high levels of staff stress and pressures.

GMB union has over 600,000 members right across all sectors and workplaces in the UK including within the NHS and social care sector. Many of our members have been on the frontline during the Covid-19 pandemic. Throughout the Covid-19 pandemic we have been working with employers - including the NHS, social care providers and local authorities - and Government to help contain the spread of the infection and ensure that front-line workers’ safety and wellbeing are looked after.

GMB union would welcome the opportunity to give oral evidence on this Committee inquiry.

Report Summary

• Long-term chronic underfunding of health and social care has resulted in understaffing in both the NHS and social care sectors. This has created an over reliance on goodwill on the existing workforce to maintain services which are struggling under staff and resource pressures.
• The Covid-19 pandemic has exacerbated further pre-existing issues around understaffing and resourcing. A workforce that has never had to deal with a pandemic of this nature or scale before has had to work harder, adapt and change work practices and take on extra responsibilities without proper renumeration or support from employers and Government.
• Covid-19 pandemic has shone a light on the crisis in regards to the supply of future health and social care workers to meet ongoing and future demands. Access to training for those looking at starting careers with in the sector but also career progression needs to be better resourced and available. The standing of the social care profession should be raised with a standardised training and career progression framework and a workforce strategy.
• We are facing a mental health crisis within the health and social care workforces and employers need to do more to provide greater support to those workers that they have a duty of care for. Government need to do more to support the oversight and coordination of what should be a national effort.
• NHS workers need a pay rise. GMB union are calling for the Government to commit to early talks on a new pay deal for NHS workers. NHS workers have endured a decade of real terms pay cuts on average losing 15% of their wages.
• To achieve parity for the social care workforce more needs to be done by Government and employers to address the poor pay and terms of the conditions of the workforce and the chronic underfunding and fragmentation within the sector. GMB believes the starting point for acheiving parity for the social care workforce is initiating a social partnership approach in care that brings together trade union representatives, service users, Government, providers and representatives of sector’s partners that commission care to scope out how this is achieved.

How resilient was the NHS and social care workforce under pre-COVID-19 operating conditions, and how might that resilience be strengthened in the future?  

The NHS and social care sectors have dealt with years of chronic underfunding and understaffing pressures, with the workforce being overworked and undervalued by Government before having to deal with the biggest pandemic the country has had to deal with in modern history.

Prior to Covid-19 staffing pressures in the NHS and social care sectors were extremely high. There were an estimated 100,000+ vacancies in the NHS and 110,000+ vacancies in social care. Reports published in October 2019 suggest there were 122,000 staffing vacancies within social care just across England – with an average vacancy rate of 7.8%.[1]It should be noted that the entire health and social care workforce have continued to work without question during the pandemic, in many cases putting their lives in danger so that they could continue to care for others. All this despite difficulties accessing the appropriate Personal Protective Equipment (PPE), testing, and sick pay in particular within social care.

Health workers adapted by being flexible in their roles at work to ensure that demand for services could be met. Many of them worked hours over and above their contracts, performed duties outside of their job descriptions – much of this at times without the necessary PPE or access to testing that they needed to keep themselves safe. Social care workers were also flexible in their approach to work – changing roles where required, moving into care homes in some circumstances – again much of the time without access to appropriate PPE and testing to keep them safe. Also, this was without access to their normal pay should they be required to take time off work.

Addressing issues around resilience for the future would mean tackling staffing pressures throughout the health and social care service and improving workplace terms and conditions. Social care has not been considered an attractive profession due to low pay and high demands.[2] Public support and perceptions of the social care workforce prior to Covid-19 was a workforce of low skill and one that is considered lower in the hierarchy of importance when compared to colleagues in the wider healthcare professions. Turnover is incredibly high amongst social care workers at 30% of directly employed staff. Whilst 66% of leavers remain within the sector there are still high numbers of workers leaving the profession. Care workers under the age of thirty are by far the most likely to leave their jobs, many of these are under the age of twenty-five and therefore are not entitled to the National Living Wage (NLW) which can be found in alternative professions. Strengthening the attractiveness of the profession by doing more to address the poor terms and conditions of the workforce must be a priority on the Government’s agenda.

The Department for Health and Social put out a national call for volunteers and former employees to return to the NHS to offer their services during the pandemic. No such call out was made for social care.

The impact of the Government’s Immigration Bill on social care is an unknown at this time but experts suggest the impact will be severe. We strongly urge the Government to look again at ensuring the social care workforce are included in the planned health care visa before the Bill passes to law.

What has the impact of the COVID-19 pandemic been on resilience, levels of workforce stress, and burnout across the NHS and social care sectors?

The Covid-19 pandemic has had a very significant impact on levels of resilience, workforce stress and burnout across the NHS and social care sectors. Health and social care staff are exhausted following long hours and extreme service pressures. Coupled with the fear of spreading the virus to patients and their own families and friends, PPE shortages, and dealing with more patient and service user deaths.

Healthcare staff have worked incredibly hard despite staffing shortages, not taking breaks, unpaid overtime or annual leave to ensure that service needs could be met. There has also been an increase in healthcare workers taking on additional responsibilities and duties without the proper training or renumeration.

This is also reflected in social care, where there have been further staffing shortages escalated still by the Covid-19 pandemic and by the fact that the workforce is older or likely to have long-term health conditions increasing the impact on the service with the number of the workforce having to shield.  GMB campaigned at the start of the pandemic that staff shielding in care be entitled to access to the Job Retention as they could not afford not to be at work. One of the biggest care providers eventually did this - who initially thought there would be 150 eligible staff, the reality was there were 1200+. Additionally, many social care staff have been denied access to normal pay should they be required to take time off work or self-isolate. Most of the social care workforce are only entitled to Statutory Sick Pay (SSP) which is an unfeasible amount - £95.85 per week – for anyone to live on. There are also considerable sections of the workforce on zero-hour contracts where we have examples of members turning down potential work only to not be given any further work by employers this again is an additional stress on those workers amplified by the risks around the Covid-19 pandemic.  

Other issues around the social care sector include the fact there are considerable numbers of part time workers and because of low pay and reduced hours do not meet the current earnings threshold for even SSP. Key workers should not have to face the stress of having to choose between surviving without a feasible income or risking not following the advice.

A Survation poll,[3] conducted on behalf of GMB union during Covid-19 identified that were facing a social care crisis as four in five care workers were expecting colleagues to quit with low pay being one of the main factors. 79% of respondents thought that staff shortages were inevitable as people were unwilling to continue working at the current levels of pay amidst the increased risk posed by Covid-19. With other results showing:

• 71% believed that colleagues would die after being infected with Covid-19 at work.
• 20% had considered quitting over the lack of Personal Protective Equipment (PPE).
• 85% felt their health was at risk due to inadequate PPE.
• 86% were worried about taking Covid-19 home to their families.

What is the current scale of workforce burnout across NHS and social care?  How does it manifest, how is it assessed, and what are its causes and contributing factors?  To what extent are NHS and care staff able to balance their working and personal lives?

Increased demand and low control in the workplace are the “perfect storm for burnout”.[4] Long hours, many of those unpaid, have left staff exhausted. This coupled with workers fears about spreading the virus to patients, friends and family at home which has further impacted staff in health and social care as well as dealing with bereavements at work.

Identifying the scale of workforce burnout is hard in the health and social sectors is difficult and GMB union believes that employers are not recording sickness leave or absenteeism around stress separately is often hidden.

GMB believes risk assessments completed on workers return to work following sickness do often not cover stress or mental health at work or if they are, they are not adequate.

At the time of writing, GMB is conducting an extensive survey of its members to better understand the workforce mental health effects of the coronavirus crisis. The interim findings from respondents who work in the NHS are particularly concerning.  Our members in the NHS report that:

• 71.28% have said that work is causing them stress or impacting on their mental health.
• When asked what is causing the stress or impacting mental health at work
• 60.95% said fear of taking the virus home
• 50.95% said fear of catching the virus themselves
• 42.86% said not being able to see friends or family
• 34.29% said balancing work and caring responsibilities
• Most of those respondents said their employer had a wellbeing policy in place - 67.57% - with 60% of those including procedures to manage stress.
• However most reported their employer did not perform specific risk assessments on stress/ wellbeing / mental health at work (43.24% saying no, 35.81% did not know) or know if their manager was trained to identify and manage mental health issues like stress (49.66% did not know with 36.15% saying no)

Most workers did not know if mental health related illness was recorded separately by their employer with 58.45% not know and 36.15% saying no. On being asked if their employer has adequate support for workers returning to work after absence due to mental health – 43.92% did not know but the majority that did said that their employer did but it was not adequate.

What are the impacts of workforce burnout on service delivery, staff, patients and service users across the NHS and social care sectors?  

A workforce that are unable to deliver the high standards of care they want to give resulting in adverse effects on patient or service user safety and satisfaction. Burnout manifests itself in the workforce feeling fatigued and unable to face the demands of their job, reducing productivity. As well as increased absenteeism and turnover of the workforce.

We also expect an increase in staff leaving their job and potentially leaving the profession all together. As mentioned above, a Survation poll conducted on behalf of GMB union during Covid-19 identified that the UK was facing a social care crisis as four in five care workers were expecting colleagues to quit with low pay being one of the main factors. 79% of respondents thought that staff shortages were inevitable as people were unwilling to continue working at the current levels of pay amidst the increased risk posed by Covid-19.

Increasing workforce burnout is also detrimental to staff wellbeing and work-life balance it is linked to higher levels of relationship breakdown, excessive alcohol use and suicide.[5] 

What long term projections for the future health and social care workforce are available, and how many more staff are required so that burnout and pressure on the frontline are reduced? To what extent are staff establishments in line with current and future resilience requirements? 

The staffing crisis in both the NHS and social care needs to be addressed as a priority for any Government. With the Government focus on trying to fill the vacancies in the NHS with differing initiatives and promises, such as 40,000 new nurses. These are pointless without genuine commitment to improving pay for these key workers who have suffered a decade of austerity and real terms pay cuts.

No such commitments are made by Government to address the staffing crisis in social care. Due to the very fragmented nature of social care, the care providers are left to resolve the issues themselves. Professionalisation of the social care workforce, through registration, national standards for training, genuine career progression and pay justice are essential if we are serious about tackling the crisis in social care. Pay justice in social care would be a real living wage, in line with local government pay structures, parity with local government terms of employment and access to the local government pension scheme.

To what extent are there sufficient numbers of NHS and social care professionals in training for service and resilience planning? On what basis are decisions made about the supply and demand for professionals in training?  

Considering the number of vacancies in the NHS and social care respectively prior to Covid-19. It is obvious there are insufficient numbers of people in training for careers or career progression in both health and social care. These vacancies also enforce a lack of career and professional development opportunities for the existing workforce with existing service demands and staffing pressures.

An apprenticeship framework was due to be agreed with the NHS Staff Council which would assist in promoting quality apprenticeships within the NHS to encourage new starters into various careers within the NHS as well as to provide existing staff with a real opportunity for career development. However, failure to reach agreement as a result of unions and employers not being able to agree on appropriate levels of pay. There are some NHS Trusts paying less than £4 per hour for apprentices – this in no way makes the NHS an attractive employer.

The removal of nursing bursaries and those for other allied healthcare professions and the introduction of fees was a huge barrier to many people being able to start training to work in the NHS. However, this would only address the nursing and allied health care profession shortages, but there are shortages across all professions in the NHS. There is also a lack of access to continuing development and career progression.

The lack of a standardised training and career development framework is an issue facing social care. Social care workers often lack career development opportunities and receive inadequate training for the work they do. This lack of a framework is from induction into the sector which often leaves workers feeling fundamentally underprepared for the role they take on. There is a reliance on induction and localised training rather than occupational registration with no legal requirement on employers to ensure engagement with the Care Quality Commission endorsed Care Certificate. The Care Certificate itself is not a qualification. Only one third of care workers in England have completed the Care Certificate, a further third has begun it but not completed it and the remaining third have not started.  There is a large discrepancy in the number of care workers in different type of services who have completed induction training.

Within social care, ‘on-the-job’ shadow-shift training is a very important practice within the sector, but it is under recognised with workers’ abilities to train up their peers not formally learnt and new starters not formally acknowledged or valued. ‘Off-the-job’ formal training is predominantly concerned with health and safety and safeguarding issues with employers motivated by reducing potential liabilities in the event of errors or accidents. The type and extent of training varies by employer and by care-setting. All training in England is employer-led, including inductions. So, we see much variation in what training consists of, the quality of the learning, who provides it, where it happens and how it is delivered and assessed. We also find there is a significant issue with funding training in social care because of the crisis in both funding and recruitment across social care it compounds

One GMB member that is a domiciliary care worker in evidence to an APPG on Social Care open evidence session in London explained succinctly: “The two days induction didn’t really teach me anything, there was very little training, and then only two hours of shadowing. I can remember getting out there and thinking I don’t know how to use this machine, what do I do? I’d been involved in PEG-feeds despite having no training.”[6]

Outside of training the national workforce the impact of the Government’s Immigration Bill and exiting the EU is at the moment an unknown in how it will impact on the supply of newly qualified NHS and social care workers coming into the workforce, but experts suggest the impact will be severe. The Social Care Workforce Study commissioned by the CAA reported: ‘33% of all nurses and 16% of care assistants are foreign nationals. In London, this rose to 65% of care assistants and 84% of nurses.’[7] We strongly urge the Government to look again at ensuring the social care workforce are included in the planned health care visa before the Bill passes to law.

Will the measures announced in the People Plan so far be enough to increase resilience, improve working life and productivity, and reduce the risk of workforce burnout across the NHS, both now and in the future?  

The People Plan in the NHS has been met with caution by GMB members in the NHS. New workplace guidance is regularly created and pushed out locally for implementation. This results in changes being forced through that staff do not always understand or agree with, often without sufficient consultation with local staff side union representatives. Management styles can cause huge difficulties with this, especially where there is lack of local trade union involvement. It is already widely recognised that there is a culture of bullying in the NHS and the roll out of standard plans with little monitoring of its implementation locally do not help ease the issue.

The People Plan focus is about improving the working experience for NHS staff, but true change must come from management first. A move away from punitive measures to a just culture of learning is essential. GMB supports a just culture process of learning the lessons from incidents, rather than punitive measures as outlined in the NHS Improvements ‘A just culture guide’. However, not all local NHS trusts have incorporated this into their local policies. There has been proven success that where just culture has been implemented the numbers of staff off sick and the numbers of formal disciplinary sanctions have drastically reduced, in turn leading to a happier and healthier workforce.[8]

What further measures will be required to tackle and mitigate the causes of workforce stress and burnout, and what should be put in place to achieve parity for the social care workforce? 

GMB Union expect a mental health crisis in health and social care of those who have worked throughout the pandemic.  We welcome support such as that launched by NHS England in the form of a dedicated helpline on mental health for NHS frontline workers, but we believe employers and the Government should do more to support efforts to invest more in occupational and mental health support for staff at the moment waiting times to use services are in some areas having waiting times up to a year.

We feel employers often have no or inadequate measures in place around supporting staff. Managers are often not trained in identifying or managing stress or mental health issues within the workforce and employers are not providing adequate support to workers returning to work following absence as a result of mental health issues.

Occupational health referrals are often seen as a tick box response without looking at possible other workplace adjustments such as time away from shifts or reduced or changed workload, reduced hours or restrictions on excessive working hours, increased rest breaks, increased one to one support with managers. Post-traumatic stress disorder support and talking therapies for health and social care staff should be arranged and fast tracked for those staff that need it and more services need to be put in place including mental health training, support with coping with bereavement. GMB supports the calls for the Government to create a post for a new independent national wellbeing guardian to coordinate and oversee support and hold Government and health and social care employers to account.

GMB Union are aware of the disproportionate impact of workplace stress and burnout on those with protected characteristics. Therefore, we feel it is essential that equality monitoring is improved by employers within health and social care so this can be tracked and stopped. Equality considerations must also be built into risk assessments and workplace support and adjustments.

Another area we believe the Government need to do more in is to address poor pay within the health and social care sector. We need experienced staff to stay in the NHS and social care where they are needed, and we need those who returned to help the NHS in its hour of need to consider staying. We can’t afford for staff to walk away because of stress, inadequate resources and poor pay.

Further to that in regard to social care, more needs to be done to address the precarious contracts, unpaid working time and addressing the balance of power which is currently massively weighted toward the employers’ interests not those that work in the sector or the service users.

The Government has not supported NHS pay to keep up with the increased living costs staff have experienced since 2010. NHS workers have endured a decade of real terms pay cuts during austerity, losing 15% of their wages on average. They were recently excluded from the Government’s announcements on public sector pay despite battling on the frontline against coronavirus. GMB union wants the government to now recognise the hard work and skill of NHS staff and the right to be paid fairly for it.

We believe the Government should make an immediate commitment to pay talks to show staff how much they are valued. Recognise the importance of pay in tackling the vacancies that exist across all sectors of the NHS workforce in every ward, team, department and clinic. Use the delivery of an early pay deal as part of the strategy for meet recruitment and retention targets and delivering safer staffing levels for patients. Integrate an early NHS pay deal into plans for helping the economy move forward given the size of the NHS workforce and the positive effect for local businesses of giving these staff more money in their pockets. Guarantee and provide the funding needed to deliver an early, meaningful and much-deserved pay rise for all staff in the NHS, including those who are employed by private contractors.

GMB Union are calling for a real term pay increase for NHS staff that makes up for the approximate loss of 15% and calling for unsocial hours enhancements that have been taken NHS staff when on sick leave to be reinstated.
 

GMB would recommend the following should be put in place to ensure care workers are properly valued and rewarded and parity with wider healthcare staff is achieved:
 

• Full and normal pay when on sick leave to be a contractual right. 
• In England and Wales, a real living wage in line with local government social care workers, including access to the Local Government Pension Scheme and other contractual terms and conditions relating to sick pay and annual leave. 
• A new funding settlement to address deep, structural problems in adult social care, including staffing levels, to meet the needs of residents and service users, providing care in homes and the community before NHS provision in required. 
• An effective model of registration in England.
• A workforce strategy that includes a national care body / service to provide a national identity for social care – professionalising the workforce with national standards for training and a career development framework.
• Sectoral collective bargaining across this vastly fragmented sector. 
• Forensic analysis of where the money (social care funding) is going.

GMB union has been calling for social care workers to be given full pay when sick. We surveyed almost 1,000 social care workers that showed that 81% of the respondents across the UK would be forced into work if they became ill on Statutory Sick Pay (SSP). It also showed a further 80% would be forced to consider borrowing off friends and family or taking on debt to make ends meet.

Social care workers deserve pay justice and a real living wage and GMB believes that they should receive pay equal to that of their counterparts in local government. Outside of England and Wales, GMB Scotland’s “Show Your Care” report believes the minimum wage should be on average £15.00 an hour in Scotland.[9]
 

The table below highlights rates of pay in social care, including those paid by some social care providers who pay the age discriminatory lower rates of pay to those under 25 years of age. These rates of pay are compared with full time local authority rates of pay for workers in social care. Rates of pay for social care workers employed by local authorities vary, but in comparison with care assistants are much higher and include incremental pay points during the workers' pay journey to the top of their pay point. This is based on information across all local authorities based on pay rates as of April 2019. 

There are also specific issues regarding the current home care sector and system. Front and centre are the way in which home care is often currently commissioned by the minute or hour. No other service that takes public money is commissioned in this way by authorities. GMB would like to see this kind of delivery of home care stopped and replaced with home care commissioned as a block of care and person centred so that providers and carers can plan their service over a sustainable shift pattern. Ensuring that carers are then paid for all their time and help stop the practise of non-payment for travel, training, hand-over and stand time.  Blocks of care should be allocated which detail an accurate picture of travel and time commitment as well as travel expenses. This would go a long way of addressing the poor morale throughout the workforce.

GMB Union believes that as a starting point for acheiving parity for the social care workforce is initiating a social partnership approach in care that brings together trade union representatives, service users, Government, providers and representatives of sector’s partners that commission care to scope out how this is achieved. We would encourage to the UK Government to look at what the Welsh Government is initiating in this area setting up the Welsh Social Care Forum.

Sept 2020