Written evidence submitted by UNISON (RTR0077)

Executive summary

• Major staffing problems existed in both health and social care before Covid-19, as a result of a decade of austerity and years of inadequate workforce planning.
• UNISON surveys of health members show an alarming number have experienced burnout and more than half are considering quitting their jobs.
• Pay continues to be a major problem in terms of ensuring the right levels of NHS staff and there is a need for a wider retention package.
• UNISON supports the Committee’s call for an urgent review of short-term recruitment and retention issues – the recognised trade unions should be involved in this.
• UNISON surveys of care workers show that virtually all have experienced staff shortages at work, with nearly a third reporting dangerously low levels of staffing.
• Decades of chronic underfunding for social care have resulted in widespread poverty pay, with three-quarters of care workers paid less than the real living wage.
• Care workers have endured a traumatic pandemic. They have also at various points suffered from a lack of appropriate PPE, no access to adequate sick pay, a failure to ensure adequate testing, and being the first to be subject to mandatory vaccination.
• Pay was virtually absent from the government’s white paper on social care, but there is no way of solving the workforce crisis without addressing poverty wages.
• There are examples of good local practice: in Somerset the council worked with UNISON and the local NHS to provide extra investment for care workers’ pay.
• The Westminster government should take a lead from Wales where domiciliary care workers are given the option of a proper contract after three months in work.
• Positive workforce initiatives in the white paper require sufficient funding if they are to make a real difference; the money allocated is a meagre £500 million over three years.
• UNISON agrees with the MAC that care workers should be immediately eligible for the Health and Care Worker Visa and should be added to the Shortage Occupation List.
• Given severe shortages, international recruitment will remain a necessity, but there should be far greater regard for the needs of sending countries. In the longer term the only way to reduce this dependence is to expand the supply of domestic staff.
• The code of practice on international recruitment needs to be given legal and regulatory teeth to ensure remedial action can be taken where breaches are reported.
• The government should scrap tuition fees for healthcare students in England and invest properly in the education workforce.
• A proper, accountable mechanism for workforce planning and the delivery of long-term workforce projections is needed, with stakeholder engagement and regular reporting.
• Until concrete financial commitments are attached to the NHS People Plan there can be no confidence that key elements will be delivered with sufficient seriousness.
• There has been no social care workforce strategy since 2009; the government should adopt or adapt plans suggested by the Future Social Care Coalition and others.
• One element that could be implemented in social care relatively quickly and at minimal cost is the establishment of proper partnership working mechanisms to mirror the NHS.
• ICSs should allow for a more rational approach to workforce planning at local health economy level and the consideration of workforce issues across health and social care.
• But integration will fail without greater parity between health and social care, and there should be no complacency about the ability of integration to improve recruitment.

Introduction

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.

2. As the largest union for both healthcare and social care staff, UNISON covers much of the workforce that this inquiry is concerned with. The union’s response is grouped under headings that broadly follow the terms of reference for the inquiry. UNISON would welcome the opportunity to provide the Committee with oral evidence in support of this submission.

Why staff are leaving health and social care, and how to recruit extra staff

3. Major staffing problems existed in both health and social care before Covid-19, as a result of a decade of austerity and years of inadequate workforce planning. Consequently, the country went into the pandemic with severe staffing shortages in both sectors: there were nearly 100,000 vacancies in the NHS at the end of 2019[1] and around 122,000 in social care.[2] Nearly two years since the first lockdown there is a serious workforce crisis across health and social care, which the Omicron surge has brought into even starker relief. The policy of mandatory vaccination, which now applies to both health and social care workers, seems set to exacerbate existing shortages as staff face redeployment or dismissal on 1 April 2022.

Healthcare

4. A large UNISON survey – based on responses before the Omicron surge hit services – found that more than two thirds (69%) of health staff have experienced burnout during the pandemic. More than half of respondents (51%) said they were covering more shifts due to staff shortages, with a similar proportion (57%) regularly working beyond their contracted hours. More than half of respondents (57%) said they were thinking of quitting their jobs, with the top reason for doing so being the impact that their work is having on their mental health (followed by issues around insufficient levels of pay and a lack of support from managers). 40% of health workers have had to take time off work for mental health reasons during the pandemic, with nearly half of those who sought help from their employer feeling that they failed to receive the assistance they needed.[3]

5. In the NHS, pay continues to be a major problem in terms of recruiting and retaining the right levels of staff. The most recent pay award for England fails to reflect the dedication of NHS staff throughout the pandemic, it fails to achieve parity with the award in Scotland; and it fails even to ensure that the lowest paid staff receive the real living wage. In terms of process, the government rejected the opportunity to engage in meaningful dialogue with NHS staff and their unions about pay – an insult made even more painful given the many sacrifices made by NHS staff since March 2020.

6. The problems run deeper than delivering a direct pay uplift in the NHS, essential though this is. In addition to setting future pay awards that prevent the service losing experienced staff, there is also a need for a wider retention package. The joint NHS trade unions will use the forthcoming pay process to set out the key aspects of such a package and have asked for urgent discussions with government on this proposal.

7. Where shortages are occurring in the NHS job evaluation may increasingly be required if staff find they are performing the duties of more senior colleagues, for example a shortage of nurses changing the scope of a healthcare assistant’s job. Nursing representatives in UNISON report that unregistered staff are commonly filling the gaps left in services. This often means they are not being paid appropriately for their work and may have consequences for the quality of care delivered by their teams. Equally, there are fears that registered staff will find they are becoming de-skilled if they have to spend more time covering for shortages in the unregistered workforce.

8. As the survey referred to above illustrates, healthcare workers have worked through the toughest two years the NHS has ever known and many are suffering from exhaustion and mental health problems. Academic analysis suggests that after the Omicron spike, the NHS could be hampered by an absence rate of up to 17% – much higher than those experienced after previous waves of the virus – due to burnout and long Covid.[4]

9. The current surge in cases brought about by the Omicron variant is having a massive impact on the workforce. Having been struggling to deal with massive backlogs of routine procedures and treatments, the NHS went into overdrive to ramp up the Covid booster programme in December. UNISON worked as part of the NHS Staff Council to produce a joint statement to remind employers of the importance of working through all other options before asking staff to cancel pre-booked annual leave over the Christmas period, and that where leave is postponed staff should be able to carry it over.[5]

10. With the NHS experiencing workforce shortages of more than 80,000 per day in early January, and the military deployed to trusts in London to help plug staffing gaps, it has become increasingly clear that the government’s failure to properly address workforce issues before and during the pandemic has left the NHS on the brink of collapse. UNISON notes the recommendation in the Committee’s recent backlog report that the government should undertake an urgent review of short-term recruitment and retention issues.[6] UNISON would support such an initiative and it would be imperative that any such review involved the recognised trade unions to ensure that the voice of the workforce is properly heard.

Social care

11. In UNISON’s most recent survey of members working in social care (which received more than 1,600 responses) virtually all of the respondents (97%) reported that their employers were experiencing shortages, with burnout, overwork and low pay cited as the main causes. Worryingly, nearly a third (31%) reported that staffing levels were dangerously low and affecting the quality of care provided.[7] This corresponds with Skills for Care data, suggesting more than 100,000 vacancies in the sector.[8]

12. This crisis has become more acute in the first days of 2022 as Omicron has affected the social care workforce. With over 11,000 care home workers absent due to Covid, many operators have declared “red alerts” in which safe staffing ratios have been breached. In the worst affected areas of London and the north, absence rates are reportedly as high as 16-22%.[9]

13. In social care, the issues around pay are even more pronounced than in the NHS. Decades of chronic underfunding for the sector have resulted in widespread poverty pay, with three-quarters of care workers in England paid less than the real living wage on the eve of the pandemic[10], and many still effectively paid less than the national minimum wage because they are not fully paid for travel time or for sleep-in shifts.

14. The continuation of extremely low pay means that the care sector is increasingly unable to compete with the likes of supermarkets and online retailers for staff.[11] Staff working in care have endured a traumatic pandemic, marked by high death rates among the workforce and at least 44,000 deaths in care homes. At various points since March 2020 many care workers have also had to operate with a lack of appropriate PPE, no access to adequate sick pay, a failure to ensure adequate testing, and then marked out as the first staff to be subject to mandatory vaccination. So it is little surprise that thousands of care workers are voting with their feet and moving to better paid work elsewhere (staff turnover within social care remains very high at 28.5%[12]). It was therefore particularly disappointing to see that pay was virtually absent from the government’s recent white paper on adult social care. There is no way of solving the workforce crisis in social care without addressing poverty wages; care workers need an urgent pay rise now.

15. Short-term retention bonuses have recently started being used in the sector to attempt to address the crisis over winter. While some extra pay is better than none, it is impossible to escape the conclusion that this is another inadequate solution to a far-reaching and longer-term problem. In some instances, employers have reported that the extra pay amounts to no more than £60 per care worker[13], and UNISON is concerned that there are no guarantees the extra money allocated will make it through to the workforce. The previous experience with the Infection Control Fund demonstrated that a system dominated by profit-making providers – and where monitoring and regulation is at best “light touch” – is incapable of ensuring that money flows to the intended recipients. The short-term nature of such a solution means that it will generally not be used by employers to pay for sustainable pay rises for existing staff.

16. There are pockets of good practice on pay. For example, following work with UNISON, Somerset County Council and the local NHS were able to announce in December investment of up to £4.8 million for increasing pay for care workers in Somerset. This will include a 9% uplift to domiciliary care providers who agree to pay all their staff a minimum of £10.50 per hour; a retention bonus for those working in care for the past six months; and recruitment bonuses for new starters in domiciliary care.[14]

17. The Committee asks a specific question about the contractual models being used. Zero hours contracts are a particular problem in social care, with around a quarter (24%) of total staff in the sector employed in this way, but this proportion rises to more than half (55%) for care workers employed in the domiciliary part of the sector.[15] Not only does this affect individual workers who find they are unable to plan ahead with any certainty and may feel unable to raise concerns due to fears that their work will dry up, but it also serves to alienate the workforce, many of whom will seek more secure employment elsewhere. If the Westminster government is serious about making social care a more attractive sector to work in, it should follow the lead taken on this in Wales where, since 2018, domiciliary care workers must be given the option of a proper contract after a three-month period of employment.[16]

18. As with the NHS, the problems in social care go much wider than pay. Persistent neglect has contributed to the low profile and low status nature of the sector, with a workforce that is under-paid, under-trained and under-valued. There are some positive initiatives that seek to address these problems in the recent white paper: for example, the focus on career progression, the tentative moves towards registration of care workers, and proposed changes to the care certificate. However, positive initiatives require sufficient funding to be attached if they are to make a meaningful difference, and the money allocated for these latest workforce items is a relatively meagre £500 million over three years.

Migration and international recruitment

19. UNISON notes the recommendations of the most recent report from the Migration Advisory Committee (MAC) that care workers and home carers should be immediately eligible for the Health and Care Worker Visa and that they should be added to the Shortage Occupation List (SOL).[17] But in terms of salary threshold, this would mean any provider employing a social care worker through the skilled worker visa would have to pay at least £20,480 per year, well above the current going rate for the sector.

20. UNISON welcomes the recognition by the MAC of the crucial, skilled work done by social care workers by placing them on the SOL. It is also significant that the MAC are the latest voice to recognise the dire funding and pay problems faced by the sector. The government should accept the MAC’s recommendations as soon as possible and listen to their warnings on pay and funding. As a first step towards treating them with greater respect and fairness, migrant workers in social care should be eligible for the Health and Care Worker Visa so that they can benefit from reduced fees and charges.

21. To smooth the path for migrant workers in the NHS the government should consider covering some of their extra costs, such as those for visas or English language tests. There should also be more investment to support transition and induction programmes so that migrant healthcare workers are given the right opportunities to develop and progress. Action should be taken on the use of repayment clauses, which are being used to exploit migrant workers and to intimidate them into staying with poor employers. Safeguards should be introduced so that these cannot be used to trap migrant workers in exploitative workplaces. Furthermore, as UNISON has repeatedly highlighted, the punitive charges for migrant workers that currently exist are not only wrong and counterproductive in the short term, but also contribute to wider racism against Black health workers.

22. Given severe shortages, particularly of nurses and midwives, international recruitment will remain a necessity for the NHS and social care in the short to medium term. But there should also be far greater regard for the needs of the countries from whom thousands of staff are being recruited. In the longer term the only way to reduce the dependence on international recruitment is to expand the supply of domestic staff. In the NHS this means scrapping tuition fees, but also putting much more investment into those educating and training healthcare students, both at universities and in clinical practice. The ultimate aim should be self-sufficiency, while maintaining collaborative relationships with other countries so that those who want to come to work here still have the opportunity.

23. The government needs to do much more to prevent recruitment from countries where it is unethical to recruit. The government’s existing code of practice on international recruitment is not legally enforceable, so when UNISON or other organisations report breaches of the code by recruitment agencies there is no provision for sanctions to be brought against rogue operators. The code of practice needs to be given legal and regulatory teeth to ensure effective remedial action can be taken where breaches are reported.

24. The government should pursue more collaborative, genuinely mutually beneficial agreements with large sending countries to ensure that recruitment happens within agreeable parameters, with unions involved as active contributors able to raise concerns and support staff. Where agreements are made with developing countries, the government should make aid and expertise available to help develop the workforce and strengthen the health systems of sending countries. The recent cuts to UK foreign aid have already undermined health partnership programmes between the UK and some developing countries.

25. UNISON would encourage the Committee to hold an evidence session devoted to the ethics of international recruitment and the rights of migrant workers. The union is developing a network of overseas nurses who could help to bolster the understanding of these issues within Parliament.

Changes to staff training

26. As mentioned above, the government should scrap tuition fees for healthcare students in England and invest properly in the education workforce. There should also be further investment in creating capacity for simulation as part of the training for nurses, midwives and allied health professionals. The technology has come a long way and could be deployed more effectively with improved funding.

27. The current system for determining how many healthcare professionals should be trained is inadequate. Health Education England is set to integrate with NHS England which poses further questions about where responsibility will lie. There needs to be a proper, accountable mechanism for workforce planning and the delivery of long-term workforce projections, which should involve engagement with stakeholders such as professional bodies and unions, followed by regular reporting and monitoring so that adjustments can be made.

28. Given these shortcomings, it is unfortunate that the government continues to resist the demands made by this Committee and many other organisations for amendments to the current Health and Care Bill so that the process of workforce reporting becomes a much more regular process than the currently planned five-yearly event.

29. Modern healthcare is increasingly complex and demanding on the workforce. There is a need therefore to closely examine the training curriculums and system of education for nurses and midwives in particular. This should consider the strain on the NHS and the existing workforce who are responsible for a huge part of students’ development, and the exhausting impact of some of the requirements on students.

People Plans and workforce strategies

30. The NHS and social care are both suffering from failings in terms of overall workforce strategy. The NHS People Plan of 2020 contained several positive elements, particularly on flexible working and staff wellbeing, but no price tags were ever attached to the various initiatives it covered and more than a year later the NHS is still waiting for something fully costed. Without concrete financial commitments for the component parts of the package there can be no confidence amongst the workforce that these items will be delivered with sufficient seriousness.

31. In social care the situation is considerably worse; incredibly there has been no national workforce strategy since the publication of Working to Put People First in 2009.[18] As noted earlier in this submission, although there are positive elements suggested in the white paper, these appear to be underfunded and piecemeal at best; there is no overarching plan to bring about sustainable change. The government appears to believe that tinkering around the edges of the system and making occasional small pots of emergency funding available will be sufficient to tackle the staffing crisis in social care. What is actually needed is a properly funded long-term plan for the workforce, which sets minimum national standards on pay and conditions and prevents unscrupulous employers from exploiting care staff. Recent work by the Future Social Care Coalition, of which UNISON is a part, has suggested the building blocks for establishing an equivalent to the NHS People Plan.[19] This was shortly followed by similar work from other parts of the sector[20], so there is no shortage of constructive work being done in this area that the government could adopt or adapt.

32. One key element that has received no coverage at all from the government, but which could be implemented relatively quickly and at minimal cost, is the establishment of proper partnership working mechanisms in social care to follow the lead set by the NHS Social Partnership Forum. A tripartite system would bring together employers, unions and government to address the most pressing issues of the day for the sector. The pandemic has demonstrated how hard it is in our fragmented care system for central government to even access essential information about local care delivery (hence some of the changes being planned as part of the current Health and Care Bill); improved partnership working could also help with this.

33. If the government is serious about integration of health and social care, it would also make sense to bring people plans for both sectors together. There are specific issues in each of the sectors that need to be addressed (as outlined throughout this submission) but there are several common issues that need to be addressed and some sense that the two sectors were pulling together with a recognition of their mutual dependency would be welcome, as would a greater focus on the ability of staff to move from one sector to the other.

The role of integrated care systems

34. While integrated care systems (ICSs) are not without their problems – and UNISON continues to raise these in the ongoing Parliamentary debates on the Health and Care Bill – they should in theory permit a more rational approach to workforce planning, allowing this to be conducted at the level of the local health economy rather than neighbouring providers competing for staff.

35. ICSs should also in theory permit consideration of workforce issues across both health and social care. It makes sense for systems to attempt a more holistic overview of workforce requirements across their patch and this could be a way of ensuring an easier path for those workers who want to move from one sector to another. The NHS Social Partnership Forum has undertaken much positive work in recent years on the NHS Staff Passport and this should be used as the baseline to protect staff pay, terms and conditions where any such moves are being contemplated.

36. Any attempts at fostering genuine integration will however continue to founder until greater emphasis is placed on achieving parity between the sectors. The lack of vastly improved funding for social care, the continued failure to provide an urgent pay uplift for care workers and the paucity of ambition of the social care white paper in terms of major system reform is deeply damaging for the care sector, but it also places a serious question mark against the government’s claims that ICSs will be able to bring about greater integration between health and social care. It is impossible to expect integration to be a success when one half of the partnership continues to operate in crisis mode, without a sufficiently ambitious route map to a more sustainable future. There should also be no complacency about the ability of integration to improve recruitment in health and social care, as the experience of mental health has demonstrated over a number of years.

Submission produced by the UNISON Policy Unit

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