Written evidence submitted by Dr Carolyn Downs (RTR0021)



Lancaster University is a leading research-intensive UK university, based in NW England. Dr Carolyn Downs is currently principal investigator for the EU funded LAPIS project, running from 2020-2023. LAPIS stands for ‘Learning for Adult Social Care Practice Skills and Innovation Development’. This project is running in the UK, Poland, Greece, Italy, and Bulgaria, and is collecting evidence about adult social care from across Europe as part of our research. In the UK we are working with (LIST ORGANISATIONS). Dr Carolyn Downs previously led the EU funded Helpcare project (2015-2018) which specifically focused on recruitment, retention, and staff development in adult social care. The Helpcare project worked across the same EU countries as LAPIS and with many UK and EU organizations supporting our research.

There are around 17,600 UK care homes and 8,800 domiciliary care providers registered with the Care Quality Commission, and on average 105,000 care sector job vacancies were advertised each day in 2020/21 (Skills for Care, 2021) while staff turnover rates have declined slightly during the pandemic to the still very high level of 34.4% (from 38.1% in 2019/20). However, early indications currently suggest turnover rates are once again increasing as the pandemic is becoming part of everyday life and are now above pre-pandemic levels (Skills for Care, 2021)

This evidence reports on adult social care recruitment, retention and training specifically, and also offers insights relevant to integration between the NHS and adult social care sectors based on data from the LAPIS and Helpcare projects.


Question: What are the main steps that must be taken to recruit the extra staff that are needed across the social care sectors in the short, medium and long-term?

Response: Our research shows the care sector struggles to recruit and retain staff for a number of reasons including poor pay and conditions, low status ( reputation as being low skilled, ‘dirty work), lack of progression opportunities, lack of suitable training, stress and heavy workloads.

We have had care managers saying, “I dread hearing Aldi is opening up nearby, as I know I will lose staff”. Domiciliary care workers report significant stress at lack of time to undertake essential tasks, and lack of time to travel between clients and cite these pressures as reasons for leaving the care sector, alongside poor pay, and low status. One care worker reported that she never told friends she was employed as a care worker, because she feared they would lose respect for her. 26% of our respondents reported planning to leave the care sector within 3 years.

Lack of training was a particular issue in job retention, leading to staff feeling ill-equipped for their role.  The care certificate is seen as of little value, as it is not externally validated, and care workers repeat the same training if they change jobs. Care workers in our study identified over 400 training needs, particularly in managing the more complex cases they work with, and were very aware that if they worked in the NHS they would be able to access comprehensive training, higher status and wages. Care workers find it difficult to understand why they cannot access NHS training provided to Health Care Assistants.

Steps to improve recruitment in the short term

Increase the pay of care workers to at least the same NHS Healthcare Assistants, which currently averages 22, 514 in the UK. We note the shortage of care workers has led to the Home Office agreeing to issue visas for overseas care workers, but specifying a minimum annual salary of £20,480, this is more than the annual salary offered by the National Living Wage after the April 2022 rise to 9.50 an hour (19,760) outside of London, for people aged over 23. Most care companies pay the government-set National Living Wage, and so will not be able to attract overseas workers on short term visa. In comparison, Lidl offers a starting salary of £10.10 an hour, with opportunities for training, progression and pay rises.

Steps to improve recruitment in the medium term

A comprehensive staff registration programme should be developed and implemented. The model developed in Northern Ireland is worth replicating in England.


Steps to improve recruitment in the long term

(Also addresses the question ‘What changes could be made to the initial and ongoing training of staff in the social care sector in order to help increase the number of staff working in these sectors?’)

Care workers and NHS Health Care Assistants should be part of a specific, registered workforce. They should have a new, professional job title to reflect this, for example, “Registered Health Care Assistants”. There should be a unified and comprehensive training package, in part funded by care sector employers, but also by government and the NHS, Bulgaria are in the process of setting up a system which offer useful lessons for the UK. The training programme should be organised by the NHS and the Further Education (TVET) sector in consultation with sectoral bodies such as Skills for Care. Work-based learning should be integral to this training and should be cross-sectoral, allowing trainees to gain experience in NHS, residential and domiciliary care settings. The initial training programme for Registered Health Care Assistants should not necessarily require specific prior learning (e.g. GCSEs) but should consider developing national assessments for soft skills to identify applicants most likely to succeed in the role. Once initial registration has been achieved there should be further, required training to allow Registered Health Care Assistants to gain further qualifications in specialisms such as stroke, stoma, dementia, general health, etc. to progress within their workplace. It should be a requirement that care providers in the public and private sector employ registered Health Care Assistants and that at least annual training takes place after registration. Our research suggests that a comprehensive training programme with registration and clear routes for further training and progression would help rebrand the sector, and improve the likelihood of younger people opting for care as a career – ensuring a future workforce.

Question: What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

Response: The fragmented model of care provision in the UK is a significant barrier to the implementation of effective and sustainable change. The NHS has plans to improve integration of care and health services, for example, the implementation of digital care plans in care homes by 2024. However, with around 17,600 care homes, and almost as many organisations running these homes, integration will prove difficult. Therefore, reducing fragmentation in the care sector should be considered. This could most easily be achieved by creating a National Care Service, and incorporating organisations into it. However, the nationalisation of private organisations may be unpalatable to the Government, so we would recommend facilitating co-operative working between organisations and making this a requirement of future contracting.

Question: What is the correct balance between domestic and international recruitment of social care workers in the short, medium, and long term? What can the Government do to make it easier for staff to be recruited from countries from which it is ethically acceptable to recruit, with trusted training programmes?

Response: There is a global social care crisis, even in low- and middle-income countries such as Nigeria and Sri Lanka. Changing demographics and family structures are leading to older people and the disabled struggling to find care and turnover rates and staff vacancies in social care are high globally.  Countries with comprehensive social care training programmes are the Netherlands and Sweden, where care staff are often degree-educated, and are well-paid. Spain also offers highly regarded training for care workers (nursing assistants). The LAPIS and Helpcare projects are not qualified to comment on UK immigration levels but do note the anomaly in salaries within the current, recently announced visa scheme, highlighted above.

Question: What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

Response: Evidence gathered across 2021 in the UK by the LAPIS project indicates that burn out features highly in the factors driving staff to leave the social care sector, due to additional pressure through high rates of the CV19 virus amongst staff, and workers being stretched beyond capacity. This has been compounded by other issues stemming from Covid 19 e.g. fear of transmission to friends and families, vaccine hesitancy, difficulties recruiting additional staff as the sector is seen as high risk etc. Low pay and status also have a significant impact on staff retention issues. Care workers have reported that they do not feel valued, and are overlooked when it comes to recognition and reward for their service to the community, despite heightened public awareness of their role because of the pandemic, and feeling virtually invisible prior to that. Care workers in England particularly resent the lack of a bonus (as given in Scotland) for working through Covid 19. Lack of career progression is cited as a factor in staff leaving the profession, with little to no clear routes for workers to advance or specialise, and certainly no real difference in pay rates and recognition for experienced carers, compared to their newer colleagues. It is to be noted that longer serving carers have reported that they are expected to help train new staff entering the organisation, through shadowing and one to one support, but receive no financial compensation for this and do this work while maintaining their own existing workload.

Some measures to address these factors would be: recognising and valuing the members of this profession through the registration process thus bringing parity across the differing staff in the sector, supporting colleagues to develop specialisms via specific and regular continuing professional development, and rewarding staff with increased pay and benefits that reflects their significant contribution to our communities.

Question: What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

Response: Currently fragmentation across the sector is impacting greatly, and the development of People Plan including BOTH NHS and non NHS staff would be a move in the right direction regarding bringing parity across the sector, and countering some of the concerns and issues that the health and care sector face, rather than produce two documents.  

Question: To what extent are the contractual and employment models used in the health and social care sectors fit for the purpose of attracting, training, and retaining the right numbers of staff with the right skills?

Response: The LAPIS project has found fixed term and permanent contracts issued to staff in the domiciliary care sector are mainly reserved for senior leadership, nurses and registered managers only. Care workers are expected to work very flexibly with rotas often changing on the day, and many are contracted using a zero-hour model. Clearly this does nothing to support staff feeling valued and is another factor contributing to low recruitment and high attrition rates. A significant lack of suitable training across the sector also affects recruiting the right number of people with the right skills, or even people with the right potential that could be trained appropriately. The LAPIS project would suggest that these contractual and employment models are not fit for purpose and need immediate review.

Question: What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

Response: The LAPIS project would recommend integrated care systems across the sector are used to share understandings and knowledge of clients, share tangible and soft resources, maximise cross sector training package availability to all relevant staff, and develop interchangeable career progression opportunities where possible. These steps would assist in both the recruitment and retention of staff with the right mix of skills, indicating the potential benefits to both the individual as a contributor to high level quality care, and with regards to developing their own professional portfolio.


Our findings are based on a large data sample and include detailed analysis of quantitative and qualitative data. We have found the problems identified by our first research project (Helpcare, 2015-2018) have not only remained unaddressed but have become more deeply entrenched in the sector and are having a greater impact on the safe delivery of adult social care. This is very concerning as all predictions show we need many more people working in adult social care, with the sector needing to recruit 1.3m workers by 2030 (Skills for Care, 2021).



This evidence represents the views of the LAPIS research team, and not those of Lancaster University or our funder. "The European Commission's support for the production of this publication does not constitute an endorsement of the contents, which reflect the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein."



January 2022