Written evidence submitted by Manchester Metropolitan University (RTR0059)
This response to the inquiry’s call for evidence is submitted by Professor Carol Atkinson, an academic in Decent Work and Productivity, a University Centre for Research and Knowledge Exchange in the Business School at Manchester Metropolitan University. Carol has extensive experience in workforce research in adult social care, and it is to this aspect of the call that the response addresses and in particular the front line workforce caring for older people. Carol has undertaken research in this field for Skills for Care, Welsh Government and Greater Manchester Combined Authority and is widely published in both policy reports and academic journals (see reference list for a selection of publications, Atkinson and Lucas, 2009, Atkinson and Crozier, 2020, Atkinson et al., 2016, Atkinson et al., 2018, Atkinson and Lucas, 2013a, Atkinson and Lucas, 2013b, Atkinson et al., 2019).
The response addresses the following aspects of the call for evidence:
Contractual and employment models
Contractual and employment models are driven, in large part, by Local Authority procurement and commissioning processes. In many instances, particularly in domiciliary (at home) care, these are procured on a spot rather than block basis and at typically less than the United Kingdom Home Care Association (UKHCA) calculated rate of delivery (UKHCA, 2018). This transfers risk to ASC providers who build this into low-paid, insecure employment models (Atkinson et al., 2016). Across the entire sector, residential/nursing and domiciliary care workers are low paid. They typically receive (at best) the National Minimum Wage and have few employment benefits. Pay levels do not reflect the responsibility borne by care workers, who often work alone and undertake tasks such as overseeing the taking of medication. In domiciliary care, up to 80% are employed on insecure, zero hours contracts (Atkinson et al., 2016). Most care workers would prefer a more secure contract, and indeed service providers would often prefer to offer this, as both parties benefit from the security that results.
Commissioning processes also typically adopt a task- and time-based approach, rather than an outcomes-based approach. In many instances in domiciliary care, this leads commissioning of very short visits, often as brief as 15 minutes, which affords insufficient time to offer what care workers consider to be good care i.e. both relational and task-based. It also often affords insufficient travel time between visits and the resultant ‘call clipping’, in which already brief visits are further shortened to allow for travel time. While care workers should be paid for travel time, this often does not happen, which further reduces their actual hourly rate of pay. Many are available for work over 12 hour periods, but are paid only for the hours they work at periods such as breakfast, lunch, dinner and bedtime (Atkinson and Crozier, 2020).
Actions to address: procurement and commissioning practice needs adapt to enable secure and fairly paid employment. Requiring compliance with Unison’s Ethical Care Charter and the Real Living Wage campaigns with serve to embed this
Recruitment in adult social care
Pay and the other employment conditions outlined above mean that care work is often not considered an attractive occupation and that the sector has long experienced a ‘crisis’ in recruitment and retention. Pressures experienced during the Covid-19 pandemic have only exacerbated this, with labour shortages set to grow as demand for care workers is increasing rapidly as the population ages (SfC, 2020). Shortages and commissioning pressures mean that strain, fatigue and sickness absence are common in the care workforce
The sector also has a negative image, due partly to a series of scandals around care quality and partly to the stigmatised nature of care work (Atkinson and Lucas, 2013a). Care work is highly gendered, ‘women’s work’ and ‘dirty work’. Yet care workers report high levels of job satisfaction derived from the intrinsically rewarding nature of their work (Hebson et al., 2015) and argue that, far from its low-skilled image, it is highly-skilled relational work (Rainbird et al., 2011). This reinforces the need for employment conditions that support the delivery of good care, and a shift away from short visits and time- and task-based commissioning. It also requires actions to shift public perception of the status of care work.
Actions to address: campaigns to improve perceptions of care work, outreach work in schools and colleges to attract younger workers into the care section
Training and careers
Training is, in theory, available to care workers, but the reality is that time and funding constraints often make it difficult to access. Levels of attainment of Level 2 qualifications remain relatively low, and this is made more challenging by workers often having to complete these in their own time and the levels of labour turnover in the sector. Management training is often lacking, with many running providing establishments based on their caring experience with little wider management development. Career paths are also limited and poorly understood, both within and outside the sector, reinforcing the perceptions of it not being an attractive career option.
As noted above, there is also debate as to whether care work is low-skilled, as suggested by the requirement for only Level 2 qualifications. In reality, the work is complex, challenging and places a high level of responsibility on workers. Training and qualification frameworks again need to reflect this. Some countries (e.g. Wales) have also introduced mandatory registration of care workers, which is a potentially important step in professionalising care work.
Actions to address: more robust regulation to ensure acquisition of induction training and relevant qualifications; better access to management training; identification of qualifications appropriate to skills involved in care work; establishment and promotion of effective career pathways; development of pay structures that reflect the skilled nature of care work and underpin career structures; mandatory registration.
Many of the issues outlined so far mean that that labour turnover in the sector is high. Yet many care workers do not leave the sector (SfC, 2020), rather they move among providers, often for only a few pence more per hour. Such turnover is, however, disruptive and challenges the continuity of care, which is so vital in a vulnerable population.
Those working in the sector are typically highly motivated by the desire to care; changing commissioning practice and improving employment conditions and work scheduling so that they can offer good care would motivational and powerful in improving retention rates. Central to this are secure employment contracts that reduce churn, work scheduling that offers both adequate visit lengths and (paid) travel time and fair pay. Reducing the strain upon care workers is also vital to improved retention and improving employment and working conditions will reduce the sense that care workers have of being under-valued, making it a more attractive career.
Actions to address: improve employment and working conditions, including fair pay, secure contracts and effective work scheduling, so that care workers can offer good care and experience improved job satisfaction and reduced strain
Planning processes are undertaken at Local Authority, rather than national, level and span public, private and voluntary sectors. This means that, particularly in the independent sector (private and voluntary), there is fragmentation of planning efforts. Skills for Care (2020) analysis evidences the need for a substantially increased workforce over coming years and more effective planning mechanism are required. This must be underpinned by many of the actions suggested above to increase labour supply to the required levels.
Actions to address: more robust people plans that span all the sectors involved in care delivery.
Integrated care systems
Integrated care is held out as the solution to difficulties across the health and social care sectors. It is indeed vital, as health care cannot operate effectively without a high functioning social care system. For example, effective social care can prevent hospital admissions for common reasons such as dehydration and falls; it is also required so that those no longer requiring health care but in need of more general support can be discharged home or to residential/nursing facilities. There has been some integration of budgets and services, and integration of teams of professionals such as doctors, nurses and social workers. There is, however, little or no integration of the health and social care workforces across the public/independent sector boundaries. This is particularly important for domiciliary care, where more imaginative solutions could see redesign of e.g. district nurse and care worker roles to both worker and patient/service user benefit.
Actions to address: a radical solution, suggested by a number of commentators across the pandemic, is a national care system that offers health and social care. Offering National Health Service terms and conditions of employment would resolve many of the difficulties around employment conditions evidenced in this response. It would also increase the status of care work and its attractiveness as a career. In the absence of this, bolder solutions on how to integrate care delivery across public/independent sector boundaries with associated role redesign are urgently needed.
ATKINSON, C. & CROZIER, S. 2020. Fragmented time and domiciliary care quality. Employee Relations, 42, 35-51.
ATKINSON, C., CROZIER, S. & LEWIS, E. 2016. Factors that affect the recruitment and retention of domiciliary care workers. Government Social Research. Cardiff: Welsh Government.
ATKINSON, C., CROZIER, S. & LUCAS, R. 2018. Workforce Policy and Care Quality in English Long-term Elder Care. Public Performance & Management Review, DOI: 10.1080/15309576.2018.1473784.
ATKINSON, C. & LUCAS, R. 2013a. Policy and gender in adult social care work in England. Public Administration, 91, 159-173.
ATKINSON, C. & LUCAS, R. 2013b. Worker responses to HR practice in adult social care in England. Human Resource Management Journal, 23, 296-312.
ATKINSON, C., SARWAR, A. & CROZIER, S. 2019. Adult Social Care technical report. In: GMCA (ed.) Greater Manchester Independent Prosperity Review. Manchester: Greater Manchester Combined Authority.
HEBSON, G., RUBERY, J. & GRIMSHAW, D. 2015. Rethinking job satisfaction in care work: looking beyond the care debates. Work, Employment and Society, 29, 314-330.
RAINBIRD, H., LEESON, E. & MUNRO, A. 2011. Is regulation good for skill development? International Journal of Human Resource Management, 22, 3727-3741.
SFC 2020. The state of the adult social care sector and workforce in England. Leeds: Skills for Care.
UKHCA 2018. A minimum price for home care. London: UKHCA.
Add Atkinson, C and Lucas, R (2009) ‘Employment Practices and Performance’, Skills for Care https://www.basw.co.uk/system/files/resources/basw_101251-10_0.pdf