Written evidence submitted by Manchester Local Care Organisation (RTR0078)
Manchester Local Care Organisation (MLCO) and Trafford Local Care Organisation (TLCO) are integrated, partnership organisations that manage teams of NHS and local authority social care staff delivering services to the populations of Manchester and Trafford.
The LCOs are virtual organisations, created and operating under partnership agreements between local statutory health and care organisations. The LCO’s do not employ staff. An advantage of this is that we have so far been able to avoid challenges posed by pay harmonisation, for example. The disadvantage of the model is that the decision-making framework and scheme of delegation enshrined in the partnership agreement have, to some extent, mitigated against a truly integrated service delivery and workforce development model
As integrated community organisations, through the workforce models currently in place, we have insight and experience of both the NHS and social care workforce and the challenges, issues and long-term needs within those workforces.
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 are:
1.1 Employment offer
As outlined and recommended in the HSC Committee ‘Social Care: funding and workforce’ report addressing the disparities in salaries between the NHS and social care is critical. The report recommends linking social care pay to equivalent bands of the NHS Agenda for Change contract and introducing meaningful pay progression for social care and references that the Government have made a commitment to bringing forward a long-term solution to low pay in social care. We support these recommendations but also recognise that this would require an increase in funding for social care.
Increased funding for social care would also facilitate full organisational integration, including integrated recruitment strategies, integrated roles and integrated career pathways (with appropriate governance frameworks in place). These are all factors which would positively enhance the employment offer across health and social care.
1.2 Cost of training
NHS bursaries are no longer available for nursing, midwifery or AHP qualifications (removed in 2017) and are only available for students studying to become a doctor or dentist and in the later stages of their qualification (year 5 onwards). There has been some adverse impact due to the removal of the bursaries particularly with a reduction in entry applications from mature students. If NHS bursaries are not to be reinstated, the funding saved by their removal could be re-distributed. Specifically, it could be utilised to provide financial support to mature students and other under-represented groups. It could also be used to provide employers with funding to support backfill costs to enable better utilisation of the apprenticeship levy (see 1.3 below).
Reinstating bursaries with reform or using the associated savings to provide financial support to those qualifying would contribute to accessibility and affordability for people to pursue careers in the health and social care sectors and therefore contribute to increasing supply of staff to meet increasing demand and service needs. It would also contribute to social mobility and workplace diversity and equality.
1.3 Use of apprenticeships
The Government need to revisit their previously stated intentions to undertake a wide-ranging review and reform of the apprenticeship levy. The apprenticeship levy can be a very viable route to health and social care careers, with at least 70 healthcare specific qualifications available and the NHS are the largest levy contributor, paying £200m per year.
There are several factors regularly cited as barriers to effective use of the apprenticeship levy, which reform could help overcome, including: the operational impact of the 20% off the job requirement; the volume of administrative requirements and for some the perception attached to the term apprenticeship. Between May 2019 and May 2021 almost £2bn levy funds expired from levy paying organisations and in November 2020 it was reported that the NHS ‘is missing out on an estimated £170m a year’ reflecting the cost of the opportunity being underutilised.
The apprenticeship levy, with appropriate reforms, can be a key part of health and social care organisations workforce strategies and create opportunity to attract and recruit from a wider pool of people from within local communities, contributing to social mobility. Without reform to the levy, the contribution apprenticeships can make to attracting, recruiting and developing a diverse and equitable health and social care workforce in the short, medium and long-term will remain limited.
The best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change is:
2.1 Domestic and international recruitment
Quantifying a correct balance between domestic and international recruitment risks masking underlying challenges with current workforce planning approaches. Rather than use international recruitment as a core resourcing channel, improved workforce planning and tackling some of the issues that limit the domestic resourcing channel (actions recommended in section 1 above) would be of benefit and reduce the reliance on international recruitment, whilst still allowing international recruitment to be a workforce development opportunity.
2.2 Support for internationally recruited staff
Due to the nature and function of the LCO any internationally recruited staff are recruited into community-based roles rather than hospital-based roles. Staff feedback tells us that it is harder to integrate as quickly when working independently in a community setting, compared to working in a hospital. To make this a better experience the Government could implement more support structures and mechanisms for those being recruited into community settings.
The following changes could be made to the initial and ongoing training of staff in the health and social care sectors:
3.1 Workforce planning
The workforce planning regime needs to be reformed to enable more realistic future forecasting of workforce requirements, particularly for registered health care professionals. Decoupling workforce planning from the financial control frameworks for NHS Trusts would allow more realistic forecasting of future requirements, based on population health data and workforce demographics.
To support career pathways and integrated career development, the focus for updating curriculums should be related to the development of multi-disciplinary pathways. This would particularly support career development for nursing and allied health advanced practitioners. Additionally, the qualifications available via the apprenticeship levy provide an opportunity to develop skills and competence of existing appropriate staff. As well as being an effective recruitment strategy, these can create career pathways and related training for existing staff to meet service needs.
In relation to whether the training period for doctors could be reduced, within the LCO workforce we do not have doctors. Our view however is that any amendments to training periods for doctors must not compromise quality and safety of patient care.
The following are the principal factors for attrition within the Manchester and Trafford Local Care Organisation:
4.1 Salary and benefits
Whilst detailed data is not available, within social care at the LCO we know that we face competition with bordering Local Authorities for salaries, particularly for more experienced staff and as cited in the ‘Social Care: funding and workforce’ report salaries within social care are uncompetitive when compared to health and other sectors. We believe it is a significant contributing factor to the average turnover (13% in November 2021) we experience in the social care population of the LCO.
Implementing the recommendations related to salary in the previously referenced Social Care Workforce and Funding report would address this as a cause of attrition for the social care workforce.
In the 2020 NHS Staff Survey, the LCO response saw a 9% decrease from 2019 to the question “How satisfied are you with your level of pay”, as the question with the largest decrease this indicates salary is also an issue within the NHS workforce as well as social care and creates risk of attrition.
4.2 Career progression
In the 2020 NHS Staff Survey in response to the question “Learning & Development activities I have completed in the last 12 months have helped me improve my chances of career progression” the LCO saw an 8% decrease compared to the previous year.
Career progression and activity to support it is a key driver of staff engagement and morale and without it, it is highly likely to contribute to attrition. Integrated career pathways, opportunities for progression in to advanced practice, better use of a reformed apprenticeship levy to support career development, more equal opportunities for career progression and promotion and organisational capacity to support development (through effective workforce planning) would all be beneficial steps to address the issues related to career progression.
4.3 Job experience
Excessive workload and organisation capacity to meet demand, exacerbated by the pandemic, is a particular issue in our workforce currently. Our results from the NHS 2020 Staff Survey highlighted an 8% decrease in response to the question ‘during the last 12 months have you felt unwell as a result of work-related stress’. In 2021 25% of absence in our health care workforce was stress related and is currently 19%. It is an ongoing concern and is contributing and likely to continue to contribute to attrition in the short-term at least.
Implementing the recommendations in the Workforce burnout and resilience report would contribute to addressing this. A more effective integrated workforce planning strategy, ensuring enough capacity and resource to sustainably meet demand would also contribute.
The following are the specific roles where recruitment and retention are a particular problem for the LCOs:
o Approved Mental Health Professionals (social care sector and a national not just local shortage)
o Sensory Rehabilitation Officers (social care sector and nationally not just locally)
o Occupational Therapists specialising in equipment and adaptations (Manchester social care sector)
o District Nurses (Manchester and Trafford)
To address the challenges being explored in this inquiry, the next iterations of NHS and social care strategic people plans should include:
The recently published HSC Committee ‘Workforce and burnout and resilience in the NHS and Social Care’ report includes a recommendation that there is a people plan for social care, aligned to the NHS people plan. Whether as two separate people plans or as an integrated people plan there needs to be much stronger emphasis, strategy and recommendations to support effective integrated workforce planning, including integrated pay and benefit structures and integrated roles and career pathways. A fully integrated people plan would have the significant advantage of providing a platform for an integrated framework for career development in the health and care sector, optimising opportunities for training and education into entry level care assistant roles and for developing experienced care workers into more advanced support worker roles and ultimately into registered health and care professional roles.
As described in the referenced report ‘the absence of a people plan for social care serves only to widen the disparity in recognition and support for the social care components of health and social care’ and as integrated health and social care organisations this, for us, is critical.
6.1 Flexible working
We recognise that flexible working as an employment model is emphasised within the NHS People Plan and that work is being undertaken nationally and locally to support flexible working and we advocate it as a model. There is more required to establish flexible working as a viable and sustainable option for the workforce, particularly providing line managers with more structure, systems and resources to build line manager commitment and support.
6.2 VCOD regulations
The pending contractual requirement for health and care staff to have received the covid-19 vaccines, whilst a point in time and of relatively small quantifiable impact, increases the risk of staff attrition and impacting attraction of the future workforce.
6.3 Workforce planning models
As referred to in point 5.1, an effective integrated workforce planning strategy is crucial and fully funded integrated workforce planning would enable development of fit for purpose integrated employment models.
6.4 Employment offer
The impact of the employment offer on attraction and retention, particularly in social care, is outlined in point 1.1 and 4.1. The Social Care funding and workforce report includes data that illustrates some of the problems. For example, at the time of the report 25% of the wider social care sector were employed on zero-hour contracts and the average social care salary is only 2% above the national living wage. Employment and contractual models such as these, prevalent in the independent provider part of the social care market, are not good enough and make it difficult to attract and recruit across the whole sector.
In terms of workforce attraction, retention and development the integrated care systems have a role to play in promoting, developing and performance managing integrated workforce planning and workforce development. This could be achieved through developing better supporting systems and frameworks and through taking on the education commissioning currently carried out by Health Education England.
Integrated Care Systems do also have a role to play in holding local health and care organisations and partnership providers to account through commissioning frameworks and financial planning, with relevant agreed standards of employment practice.
We welcome this inquiry and the opportunity to provide our feedback and perspective. Much of what we have raised through this inquiry relates to and is also included in the two recent reports referenced throughout this document. Several recommendations from those two reports would substantially contribute to dealing with the challenges and issues being explored through this inquiry and as such we feel all three inquiries are interdependent.
The key questions we believe the committee should ask the Government: