Written evidence submitted by Care England (RTR0069)
Care England, a registered charity, is the largest and most diverse representative body for independent adult social care providers in England. Membership includes organisations of varying types and sizes, amongst them single care homes, small local groups, national providers and not-for-profit voluntary organisations and associations. Between them they provide a variety of services for older people and those with long term conditions, learning disabilities or mental health needs.
Care England appreciates the work that has been done so far to help mitigate some of the workforce pressures currently faced by the social care sector but we must emphasise that much more still needs to be done. Care England’s second Workforce Sense Check Survey, which ran between 1 December and 8 December, highlighted that over 95% of respondents were struggling to recruit staff at the time of the survey, and 75% were struggling to retain staff; issues that are still ongoing for members. The adult social care sector is still far from being put on an equal footing with the NHS and is still often thought of as the poor cousin of the NHS. The care sector has been affected seriously by the effects of the COVID-19 pandemic because of this lack of an equal footing and the misunderstanding of what the sector does. There is a great danger that nothing will be learned from the pandemic and, as a result, the care sector will continue to suffer.
Professor Martin Green OBE, Chief Executive of Care England, would be willing to give oral evidence at future Committee meetings. As a critical friend to Government, Care England wants to help be part of the solution and is delighted that once again the Health and Social Care Committee is moving the agenda forward.
What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?
Whilst Care England recognises that some support has been given to the adult social care sector by way of the two Workforce Recruitment and Retention Funds, amounting to £462.5m, this funding still falls woefully short of the £700m announced for the NHS this winter; the NHS cannot continue to have a lion share of the funding for health and social care. Therefore, it is prudent that the Government and Local Authorities support providers to act pragmatically to recruit the staff needed to reduce workforce shortages.
In addition to this, Care England members have reported that they have lost in excess of 12% of their workforce as a result of the implementation of the Vaccination as a Condition of Deployment (VCOD) policy on 11 November 2021 as per Care England’s second Workforce Sense Check Survey; 71% of respondents feel that the policy has affected their ability to recruit. The DHSC’s Impact Assessment for VCOD in care homes assumed a cost of recruitment per worker of £2,500 based on evidence from the sector. In order to help facilitate the recruitment of the extra staff to cover those that have been lost it is therefore important that the Government recompenses providers the recruitment costs incurred as a result of the VCOD policy. Whilst Care England acknowledges that the two Workforce Recruitment and Retention Funds have attempted to recompense some providers, many providers have seen little benefit due to the conditions imposed at a local level.
Further, agency fees have continued to increase and is thus making agency staff an unaffordable option for providers to fill workforce shortages. Some providers have reported being charged more than £90 an hour for vaccinated agency nurses, which is largely unsustainable. Concerningly, it has been reported that agency costs have increased as a direct result of Government imposed policies, such as VCOD, as care homes battle to hire those agency staff that have been vaccinated. Therefore, it is essential that the Government introduces better regulation over care staff agencies and controls the fees they are charging providers for the use of these agency staff. It is worth noting, however, that although agency has become a necessity for care providers, it is not a favoured option for all individuals requiring care. This in particular applies to those individuals with learning disabilities or dementia who require specialist one to one care, with their care worker knowing the resident well. Therefore, the Government must consider all other options suggested in this response to help support the influx of workers beyond agency.
Care England welcomes the Migration Advisory Committee’s (MAC) decision to make care workers immediately eligible for the Health and Care Worker Visa and placing the occupation on the Shortage Occupation List. Care England had long called for care workers to be added to the Shortage Occupation List, hosting a roundtable with the MAC in October 2021 to evidence the importance of this decision. This is a step towards facilitating a growth of recruitment from abroad however, more needs to be done to encourage, as well as ease the process of, overseas recruitment such as waiving the Immigration Skills Charge for care workers.
Care England has called for increased support from the Department for Work and Pensions to push for greater adult social care involvement in initiatives such as the Sector-Based Work Academy Programme (SWAPs) and the Kickstart Scheme, and to improve Job Centre support for individuals. Greater involvement of adult social care in these initiatives will help to create more awareness of work in the social care sector and could encourage more individuals to pursue a career in care. Whilst we recognise that the Government has lent attention to this ambition, including the National Recruitment Campaign, we are yet to see what tangible outcomes these campaigns have produced. The care sector is immensely diverse and this nuance is often overlooked; care is delivered to a variety of individuals of varying ages and needs and the sector’s workforce must be appropriately bolstered to reflect this.
Care England suggests that a new apprenticeship programme is set up that crosses both health and social care. This new programme needs to be a building block for the integration agenda to ensure that there is greater parity between the NHS and the social care sector. Of note, the care sector has come together to work on an initiative to attract more employees from other sectors into pursuing a career in social care. This initiative has very much been based on the successful work done by Teach First and Teach Now. Care England believes that this can be replicated across the social care sector and we hope this is an initiative that the Government can support.
Care England’s second Workforce Sense Check Survey, which ran between 1 December and 8 December, highlighted that almost all of those who responded noted poor pay and a lack of benefits for social care staff as reasons why it is hard to recruit into the sector. Therefore, one step that must be taken to enable the recruitment of the sufficient numbers of care staff is to increase the pay and benefits for social care staff to make the sector more attractive. This poor pay and lack of benefits often incentivises social care employees to move to other sectors, such as retail and hospitality, where they are being paid more for better hours and less stressful work. Further, the Unfair to Care report published by Community Integrated Care in July 2021 reported that social care workers are being undervalued by nearly £7,000 per year compared to their peers working in the NHS and other public funded sectors. This undervaluing is something that care providers will be unable to lessen without sufficient support and funding by the Government. Care workers are often perceived to be ‘just a care worker’ and this negative stereotyping needs to be quashed.
Local Authorities must also give providers the necessary funding to allow for uplifts in pay rates. As adult social care providers fees are fixed with Local Authorities and are reviewed annually it means that providers do not have the same ability as other sectors to increase pay as flexibly. This removes the ability for care providers to compete with other sectors and thus Local Authorities must help support fee increases for care providers. Care England is supportive of good and fair wages and for too long, the Low Pay Commission’s recommendations have not been matched by adequate Government funding. The 2021 Low Pay Commission Report noted that increases in funding have generally failed to match the pace of the rising minimum wage which has in turn caused difficulties for the social care sector; an issue that needs to be resolved.
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?
Given that there is an increasing population of those with increasingly complex comorbidities it is vital that there is a growth of specialist training to help staff deal with these changing needs. Staff need to continue to feel supported and adequately trained and equipped in caring for residents with changing needs. It is incumbent upon central Government to help facilitate and fund training initiatives which recognise the changing demographic and epidemiological landscapes of the population.
As the use and development of technology continues to excel and we become more heavily reliant on technology in adult social care, it is evident that these changes will also likely impact the nature and content of the training that needs to be offered in the adult social care sector. Therefore, it is essential that new training and funding to facilitate this training is offered to the sector so that staff are able to keep up-to-date with any new changes. The pandemic has demonstrated the sector’s capability and eagerness to adapt digital technologies. Through remote monitoring, care providers are able to deliver faster more streamlined care, while also reducing the burden of administration and thus freeing up time for staff to deliver essential care. This is just one example of the digital developments that are taking place in adult social care.
Care England has consistently stressed the need for a wider workforce strategy which could be decoupled from long-running discussions about the sector’s funding. Care England strongly believes that a 10-year workforce plan, akin to that of the NHS, is required to help the recruitment, retention and training of staff in adult social care. Care England has previously supported the amendment in the Health and Care Bill to include provisions to require Health Education England to publish objective, transparent and independently-audited annual reports on health and social care workforce projections that cover the next five, ten and twenty years. However, we note that this amendment did not succeed in the House of Commons, but hope that it will do so in the House of Lords. Care England believes this creates a gap between Ministerial rhetoric about supporting frontline staff and refusal in practice to implement the biggest single long-term change that would relieve the pressure that staff face. It is vital that the Government gives hope to staff that the appropriate number of new staff will be trained in the future to reassure frontline staff that they have control over the problem. Further, this 10-year workforce plan must help to identify career progression, training, pay and reward for adult social care staff.
What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?
The correct balance between the two is one that allows for workforce shortages to be reduced and the one that helps to facilitate an influx of workers to the sector to ease the difficulties caused by a shortage of workers.
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?
In order for the Government to make it easier for staff to be recruited from abroad they should consider facilitating an influx of “unskilled” workers to increase the overall supply of workers. Providers have reported that, as a result of Brexit and other factors, they are now able to recruit from a much smaller pool of candidates, who often choose to work in more attractive sectors, such as retail and hospitality. Therefore, facilitating an influx of these “unskilled” workers would help to expand the pool of candidates from which providers are able to recruit from and may help to mitigate some of the competition issues faced when recruiting abroad.
Further, it is evident that VISA restrictions often make it difficult to recruit from abroad and thus removing these VISA restrictions entirely would remove the difficulty and/or barriers to employing from abroad. Care England believes that removing these restrictions entirely and returning to ‘freedom of movement’ with a rapid pathway to ‘right to remain’ for any workers employed in social care would help to make it easier for staff to be recruited from abroad.
What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors?
Currently, a career in adult social care is one that is often not made obvious or emphasised enough to student nurses and thus, nurses more often than not choose a career in the NHS. Care England, therefore, believes that it is vital that the relations between care providers and nursing institutions are developed to encourage more nursing student placements in the adult social care sector. This will not only help temporarily resolve some workforce shortages in the short-term when students are on placement, it will also help to emphasise and create a greater interest in the adult social care career path for staff once they are fully qualified. The development of these relations will play a vital role in developing the future of the adult social care workforce. The Autumn Spending Review reaffirmed the Government’s ambition to recruit 50,000 more nurses for the NHS by 2025 and failed to acknowledge the need to recruit additional nurses into the social care sector. This is but one initiative that evidences the lack of parity between support for the NHS and social care.
Scotland, Wales and Northern Ireland all have their own professional register of care workers which helps to oversee the registration, workforce and promotion of high standards of professional conduct of social care professionals, among other things. England is currently the only nation in the UK without this professional register of care workers. Care England therefore believes that the introduction of an English professional register of care workers could help to raise the status of working in social care which would in turn increase the attractiveness of work in the sector. Further, successfully implementing the registration of care workers in CQC registered services could help to lay the foundations for professionalising the care workforce.
Further, the Health Education England Long-Term Strategic Framework Review must ensure that social care is not lost within the NHS review. Care England is glad to see that for the first time ever, the framework will also include regulated professionals working in social care. However, it is essential that the review of social care is treated equally as important as the review of the NHS and that the voice of social care leaders is not overlooked. It is prudent to say that without sufficient support of the social care workforce and the pressures being faced by the sector, the NHS will suffer as much as the social care sector.
Care England believes that the Government, with the support of the social care sector, needs to develop some clear skills and competency frameworks, and a set of portable qualifications for social care staff. This will enable employees to move more easily between employers in social care, as well as allowing ease of movement between the health and social care sectors.
What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?
Care England has continued to stress that the low rates of pay and lack of benefits and reward for social care is one of the largest factors driving social care staff to leave the sector. Competing sectors are able to offer higher rates of pay for fewer hours and less emotionally challenging work. Further, some employees are returning to pre-COVID jobs or are moving into other sectors that appear more attractive, such as retail and hospitality. Consequently, increasing the rate of pay for social care staff will not only help to recognise their hard work, especially in times of COVID, it may help to incentivise staff to work in a better paid sector and will encourage staff retention.
Care England welcomes the decision to uplift the National Living Wage in April however, it is important to note that this may present difficulties for providers. Providers rely on Local Authorities to increase funding to support this pay uplift and without this funding providers will be hit with heavy financial costs to implement this increase. It is essential that these uplifts in pay for social care staff are supported with enough funding for Local Authorities to pass onto providers to implement the uplifts in pay rates. It is not enough to introduce higher rates of pay without the funding behind it to support the increase.
Moreover, social care staff are experiencing high levels of burnout due to the implications of COVID-19 and the heavy workloads that have resulted from the pandemic. These high levels of burnout are only further exacerbated by the need for staff to cover extra shifts as a result of workforce challenges caused by staff leaving, staff absences, or the need to self-isolate. There is also a lack of recognition of the hard work done by social care staff and, often, social care is not thought about or considered in Government guidance. It is essential, therefore, that the Government introduces reward and recognition for social care staff through things such as staff retention bonuses. Whilst these bonuses have been introduced in some Local Authorities, as well as other regions of the UK, it is not consistent and this should be done nationally to recognise the hard work of all social care staff. Further, some providers are offering golden hellos by way of up to a £10,000 “welcome bonus” to encourage workers into the sector. HC-One, for example, is offering £10,000 for registered night nurses in Scotland whilst the Priory Group is offering £5,000 for mental health nurses. This is an initiative that the Government ought to consider funding to help facilitate an influx of workers into the social care sector.
Staff burnout is fundamentally intertwined with reward and pay and thus, we would ask that the Government commits to a long-term funding solution that allows for care workers to be appropriately rewarded for their work. However, staff burnout will not only be resolved by the introduction of staff retention bonuses and an increase in pay. Therefore, Care England calls for the Government to take into consideration methods to support the wellbeing of social care staff. A support fund for providers is required to allow them to allocate the necessary resources to care workers to support care worker access to face to face peer support and helplines. In light of the effects of COVID-19, there must also be an increase in the access to specialist PTSD support given to the adult social care sector so as to ensure that they are fully supported for all mental health issues that may have arisen. If staff wellbeing is not sufficiently supported, it will only exacerbate staff burnout and retention issues.
Unlike the NHS, social care does not have a clear or set career pathway that creates an ease of understanding for how staff are able to progress in their careers in social care. Whilst Care England recognises that the review of health and social care leadership is being undertaken to help recruit and retain the best leaders from the start of their career through to retirement, it is essential that career pathways in social care are fully considered. Social care does not have clear career progression and thus, some staff do not fully understand what needs to be done to make a career out of care which causes some staff to leave the sector. Therefore, the Government needs to fully consider implementing clear career progression for social care staff, which involves continued training and pay progression, to encourage more staff into the sector and to encourage more staff to stay.
Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?
Care England’s first Workforce Sense Check Survey, which ran between 30 September and 7 October 2021, shows that members are having the most difficulty recruiting direct care roles (98%). However, members also reported they are struggling to recruit management roles (11%), regulated professional roles (15%) and ancillary roles (17%). Whilst direct care roles are a particular problem for providers to recruit into, it is evident that recruitment issues are occurring across all areas of the sector. The initiatives in which Care England supports to help address these recruitment and retention issues have been discussed in response to earlier questions in this inquiry.
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?
First, it must be emphasised that the next iteration of a People Plan should not solely focus on the NHS and must take into full consideration the needs of the social care sector and its staff. Care England calls for the Government to introduce a social care People Plan that is separate to the NHS People Plan. Without an adequately supported social care sector, the NHS will not cope.
Social care staff, needless to say, have excelled throughout COVID and have increased their expertise of working in the care sector and thus have upskilled via the various lockdowns and as a result of everchanging Government guidance. This upskilling needs to be recognised and celebrated by Government through implementing proper and formal training to increase the upskilling of staff. A continued focus on the upskilling of staff will help them to develop their skills and capabilities and to supplement them with a clearer career progression for staff. This focus on upskilling of staff will not only improve the continued training of staff but will also incentivise individuals to stay in a sector that has a clear career pathway. Furthermore, the creation of a better, long-term career pathway and progression for social care will help the sector to be seen more of a permanent, long-lasting career as opposed to being seen as a place to go to for temporary work, as well as encouraging more student nurses to pursue a career in care. In addition to encouraging student nurses to enter a career in care, it is also essential that the Government encourages young leaders to pursue a career in care. Care England calls for the Government to introduce a social care leadership graduate programme, akin to the NHS graduate programme, to encourage graduates to enter social care and to see it as somewhere with great career prospects. Whilst this was considered before, the funding was cut and therefore we call for this option to be reconsidered by the Government.
In the short term, particularly as the social care sector is in a time of crisis, it is important for the Government to introduce mechanisms to encourage trained volunteers to support the social care sector and not just the NHS. This will help to fill some short-term workforce gaps whilst other individuals are progressing through their training. It is important to recognise that social care needs volunteers just as much as the NHS does and without which the NHS and social care sector will end up suffering.
As we enter an increasingly digital age it is essential that the training of social care staff is kept up to date with the continued changes, or new introductions, of technology in care. The use of technology already is, and will continue to be, something that those working in the care sector heavily rely on and thus training must be kept in line with this. Care England asks for the Government to increase funding for the social care sector so that they continue to support and train a workforce that is up to date with all digital and technology and does not fall behind its NHS counterpart. Further to this enhanced training, it is important that mechanisms are introduced to ensure that social care staff feel fully supported in their training, whether that be before, during, or after, so as to ensure they do not leave the sector due to a lack of support. This support can be provided through staff wellbeing support measures as mentioned previously.
Although the White Paper promises greater integration between the health and social care workforce, with many ICSs committing to ensuring this, consistency will be key. If one ICS fails to provide essential training opportunities for their local care providers, it will create a disparity amongst the systems. Therefore, it is crucial for accountability measures to be in place for systems, or local authorities that fail to support the digital development of the ASC workforce.
Similarly, all commissioners involved in using ASC data must be correctly trained to understand it. Care providers understand their data better than anyone and should be consulted on how to correctly use it to improve the lives of those they care for. Working in collaboration will help ensure a more efficient health and social care system that is also integrated.
In addition to the above recommendations, Care England calls for the Government to offer social care staff a pension scheme that is akin to that of the NHS pension scheme. The work that care sector employees undertake is equally as valuable as the work undertaken by NHS colleagues and thus their work ought to be appropriately recognised and rewarded in the same way. Given that the care sector currently employs a high proportion of individuals approaching retirement age, it is essential that the Government ensures staff will be well supported in their retirement and will help to retain staff who may be lost to the NHS due to their more attractive pension scheme.
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?
The work of social care staff is difficult and highly complex, especially when caring for those individuals with increasingly complex comorbidities. Therefore, further Government support would be welcomed to help recognise this hard work and encourage more individuals to enter the sector. Some care providers are offering a £10,000 “welcome bonus” for registered night nurses and others have introduced staff retention bonuses for those staff that have worked for a certain period of time. Care England asks the Government to consider its capacity to provide central support for initiatives like this so that social care staff are appropriately remunerated for their hard work. Similarly, Care England would call for the Government to implement a reward scheme similar to those that have been implemented in Wales and Scotland that gave staff a £500 bonus.
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?
Care England hopes that the introduction of integrated care systems in July 2022 will help to promote true integration between health and social care. This will be of benefit to both service users as well as those that are employed within the sector. It is vital that the voice of social care is not lost with the introduction of ICSs and that leaders in social care are involved in all decision making that affect the social care sector. Social care leaders hold essential knowledge of the social care system and thus, their voice matters in helping ICSs ensure that care organisations attract and retain staff with the right mix of skills.
Care England would be willing to give oral evidence to the Committee.
Professor Martin Green OBE