Written evidence submitted by Centre for Care, University of Sheffield (RTR0103)

This response is provided by members of the ESRC-funded Sustainable Care: connecting people and systems team, and the ESRC Centre for Care.

University of Sheffield: Tom Hunt, Prof Sue Yeandle, Dr Kelly Davidge

This response focuses on lessons that can be learned from the introduction of mandatory vaccination for care home workers and is based on Hunt, T. (2021) Under-paid and under-valued: assessing mandatory vaccination for care home workers in England (Sustainable Care Paper 4, CIRCLE, Sheffield: University of Sheffield.) The paper is a review of evidence on mandatory vaccination, including the government’s consultation on the policy.

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

Factors behind the lack of enthusiasm for mandatory vaccination in social care may also explain why staff turnover in the social care sector is high and why some care home workers have chosen to leave their employment in recent months.

The vast majority of the British public are in favour of compulsory vaccination for all UK adults but most respondents (57%) to the Government’s consultation on Making vaccination a condition of deployment in care homes were opposed to the new policy. One important objection was that “the structure of employment in care creates barriers for care home workers to get vaccinated”.

The employment model for care workers is characterised by:

• Low pay (median hourly pay for care workers is £9.01);
• High levels of job insecurity and uncertainty about the availability of work (24% of workers in the sector are employed on zero hours contracts [ZHCs]. 42% of the home care workforce are on a ZHC);
• Poor terms and conditions of employment; and
• Limited opportunities for training and career progression.

Our review of the available evidence highlights that pay and conditions of care workers are significant factors in understanding why some remain unvaccinated, and are indicative of wider problems in the social care sector:

• Uncertainty for individual workers about the availability of future work;
• Care workers commonly work shifts (often with unsocial hours), hold multiple jobs, and balance work with their own (unpaid) caring responsibilities;
• Failure of some employers to give employees paid time off, for example to attend vaccination appointments.

These factors mean that workers on low wages who may be uncertain about the availability of future work (due to their ZHC status and unpredictability of shifts) often cannot afford to take time off to attend vaccination appointments. In addition, low-paid workers who have concerns about possible side-effects from vaccines, may feel they cannot risk having to take unpaid time off, if they feel unwell following vaccination, for fear of losing essential income.

We argue that the objections to vaccination by care home workers represent a wider crisis of work in the sector, not just a crisis of recruitment and retention.

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?

We again take this question through the lens of mandatory vaccinations for care workers.

• Improve jobs (to improve jab take-up) and to recruit and retain staff. Most care workers are dedicated to their work, but many are exhausted and burnt-out by their experiences at work during the pandemic.
• Care workers face an employment situation of low pay; long hours, with unpredictable and unsociable shift patterns; poor terms and conditions; and limited opportunities for career progression.
• Care home workers are under-paid and under-valued. The persistence of low pay that is falling behind other sectors is further evidence of the undervaluing of care work, as is the Government’s continued delay in setting out proposals for care sector reform.
• The sense that care work is not valued or appreciated feeds into wider concerns that the voices of care workers and others in the sector are disregarded, compared to the NHS, and that the sector is ‘powerless’.
• Are care workers considered to be ‘professionals’? Professionalisation in care, and the ability to exercise ‘professional autonomy’, is intrinsically linked to the employment conditions of care workers.

We argue that there are a number of lessons to learned from the introduction of mandatory vaccination for care workers, and consider the following questions salient:

• Would more care workers have voluntarily chosen to receive vaccination if their work was better-paid, and provided better security and benefits (such as sick pay) and opportunities for progression?
• Would the care sector face long-term challenges in recruiting and retaining staff if employment conditions in the sector improved?
• Would the prevailing ‘low pay, poor conditions’ employment model in care persist if the care system received the funding it needs?
• Would mandatory vaccination have been introduced if the care sector had forums equivalent to those in the NHS in which workforce voice was heard? Would the prevailing ‘low pay, poor conditions’ employment model in care persist if such forums existed?
• Would care work be better appreciated if care workers’ pay and conditions were improved and the sector provided more attractive career opportunities?
• Would questions about the enforcement of mandatory vaccination, its potential discriminatory effects, and the legality of the policy remain unanswered if the sector had a stronger unified voice?
• Would mandatory vaccination have been introduced if care workers had a professional status equivalent to that of healthcare professionals?

If planned reforms set out in the Social Care White Paper are to establish the long-term settlement the sector needs, all stakeholders will need to be involved in their design and implementation. Care workers should be fully involved in the reform process to improve the contractual and employment models in social care; these are currently not fit for the purpose of attracting, training, and retaining adequate numbers of staff with the right skills. The introduction of mandatory vaccination for care home workers has exacerbated the recruitment and retention crisis in care. It provides an illustration of the unintended consequences that can occur when the voices of the workforce are not heard, and their concerns are not listened to and acted upon. Central to those concerns is the strong sense amongst the workforce that they are under-paid and under-valued, and that their concerns about the employment arrangements many care workers experience - of low pay, zero-hour contracts and poor terms and conditions, including a widespread lack of decent sick pay - are being ignored.

Jan 2022