UNISON – Written evidene (NHS0081)

Executive summary

• There is a need to consider the future sustainability of social care alongside that of the NHS.
• Mental health and tackling health inequalities need greater priority attached to them.
• The future healthcare system should abandon the failed experiment with markets.
• The comprehensive NHS model of care being delivered free at the point of need should be retained, and ultimately extended into the social care sector.
• The sustainability of the NHS model as a healthcare system has been assessed recently by a number of organisations with a consistent picture emerging of strong support for the NHS.
• The Committee should therefore accept this consensus as a starting point and deal with other areas such as healthcare funding, models of service delivery and the crisis in social care.
• There should be no moves to restrict what is free at the point of use on the NHS.
• Within the current funding envelope, the NHS is fast approaching a state of financial meltdown.
• While the headline decision to front-load NHS funding was preferable to leaving increases until later in the Parliament, this still represents a relatively meagre settlement for the NHS.
• And the wider Department for Health budget has been slashed, meaning less money for public health, health education and the operation of arm’s length bodies.
• The NHS is also under pressure to deliver an unrealistic £22bn of “efficiency savings”.
• The situation in social care is far worse, with the council tax precept and Better Care Fund insufficient to bridge the widening gap between funding and need.
• UNISON has long pointed to the folly of government attempts to restrict the supply of overseas healthcare staff to the UK; the situation will not be helped by the UK leaving the EU.
• UNISON, along with many others in health and social care, is calling on the government to make a firm commitment that EU migrant workers should be permitted to remain in the UK.
• Staffing shortages and the mounting agency bill all point to the fact that the government’s policy of pay restraint in the NHS is no longer sustainable.
• The removal of bursary funding for healthcare students and the impact of Brexit on the supply of staff to work in the NHS are set to make a bad recruitment situation even worse.
• The lowest NHS pay scales need to be restructured to build in a sustainable Living Wage commitment for the whole of the NHS.
• The NHS Pension Scheme remains a key element of the overall reward package for NHS staff and, if undermined, also has the potential to affect future recruitment and retention.
• Removing the NHS bursary is likely to affect the supply of healthcare staff to the NHS, exacerbating current shortages and affecting patient safety.
• With the current mismatch between skills shortages and availability of apprenticeships, the apprenticeship levy means that the NHS is unlikely to recoup its money in the first years.
• There is likely to be a shortfall in funds to support planned learning, with particular implications for the provision of continuing professional development in the NHS.
• The ambulance sector illustrates how failings in workforce planning, problems around recruitment and retention, and issues with skill mix are affecting staff and the quality of service.
• There are even more pressing issues concerning the social care workforce, with non-payment of the national minimum wage endemic in the sector.
• UNISON is encouraging councils to improve the delivery of homecare services by adopting the Ethical Care Charter, which has already had positive results for both staff and service users.
• UNISON supports the principles of health and social care integration, but with caveats around the need for engagement, protecting terms and conditions, and it not being a cover for cuts.
• There is also a need to challenge the assumption that integration will automatically bring about substantial cost savings.

Introduction

1.      UNISON is the major trade union in health and social care and the largest public service union in the UK. We represent more than 450,000 healthcare staff employed in the NHS, and by private contractors, the voluntary sector and general practitioners. In addition, UNISON represents over 300,000 members in social care. The union’s community and voluntary sector has an expanding membership of more than 60,000 and UNISON has a large retired membership of more than 165,000 with a particular interest in the future of health and social care. In addition, there is a wider interest among our total membership of more than 1.3 million people who use, or have family members who use, health and social care services.

2.      The TUC has produced a comprehensive submission to this inquiry, which UNISON fully endorses. Rather than repeating the same points this submission includes some additional ones, particularly focused on resource issues and the workforce section of the call for evidence. Many of the specific questions posed by the Committee are inter-related, so this response is structured around the main headings outlined by the Committee rather than addressing each of the questions individually.

The future healthcare system

3.      Demographic change and an ageing population undoubtedly provide greater challenges to the future health and care system, but we should begin by welcoming the fact that many more people are living for longer and enjoying many more healthy life years than previously. This is testament to the success of the NHS – and those that work in it – in bringing through medical advances and new ways of working.

4.      In terms of how the health and social care system needs to change by 2030, UNISON echoes the submission by the TUC and the evidence of the Nuffield Trust to the Committee, around the need to consider the future sustainability of social care alongside that of the NHS. Decades of chronic underfunding means that social care is not only experiencing a crisis of its own, but is also having an increasingly detrimental impact on the NHS. Delayed discharges from hospital are now at record levels, with patients taking up hospital beds they no longer require accounting for more than 184,000 days in July 2016.[1] While a lack of social care capacity is not the only reason for this, it is a major factor. The Respublica think tank predicts additional costs of up to £3bn for the NHS as a result of the loss of social care beds.[2] 

5.      Mental health is another area that needs to have greater priority attached to it. Parity of esteem for mental health is a policy that UNISON supports and the extra funding for mental health as a result of the Comprehensive Spending Review (CSR) and in response to the work of NHS England’s mental health taskforce is welcome. However, there are real question marks over whether this will be enough to reverse the decades-long trend of mental health being seen as a Cinderella service, and whether the money will actually make it through to where it is most needed. UNISON notes the findings of the recent Public Accounts Committee report that only a quarter of people estimated to need mental health services have access to them, and that current government plans to improve services are unrealistic due to budget pressures.[3] Similarly, recent reports suggest that more than half of clinical commissioning groups plan to actually reduce the proportion of their budget they spend on mental health.[4]

6.      The universal nature of the NHS is essential to our healthcare system remaining amongst the most equitable in the world. However, health inequalities persist and need to be tackled in a more concerted manner. For example, greater investigation is needed into the impact of various initiatives to boost patient choice by successive governments and the potential this has to put poorer people or migrant workers, for example, at a disadvantage compared to those who are more used to asserting their rights to choose or who are more familiar with the workings of the UK health system.

7.      Related to this, the future healthcare system should abandon the failed experiment with markets. This has largely been resisted in Scotland and Wales anyway, and now in England the success of the Five Year Forward View, particularly its Sustainability and Transformation Plans, depends on the NHS being able to operate free of the shackles of the full-blown NHS market that the Health and Social Care Act 2012 sought to bring about. The use of competition law and economic regulation should no longer be an impediment to different parts of the NHS working together to further the interests of patients.

Resource issues, including funding, productivity, demand management and resource use

8.      In terms of future funding models for the health and care system, UNISON favours the retention of the comprehensive NHS model of care being delivered free at the point of need, and ultimately the extension of such a model into the social care sector. UNISON is not the only organisation that supports such an ambitious settlement; the Barker Commission for the King’s Fund recommended that in the long run much more social care should become free at the point of use.[5]

9.      There should be little need for the Committee to revisit the sustainability of the NHS model as a healthcare system, as this has been assessed very recently by a number of august organisations and commentators with a consistent picture emerging of strong support for the current set-up. For example, the Barker Commission in 2013 found no reason to do away with the model; instead, as noted above, looking to expand it into parts of social care. In 2014 the NHS Five Year Forward View provided definitive confirmation that the NHS model of tax-funded comprehensive services is sustainable.[6] And the New York-based think tank the Commonwealth Fund rated the NHS top overall in its most recent survey of comparable health systems; it was particularly significant that the NHS came top on the question of efficiency.[7]  UNISON therefore calls upon the Committee to accept this consensus as a starting point for the rest of its inquiry and move on swiftly to deal with the more vexed questions about healthcare funding, models of service delivery and how to tackle the crisis in social care.

10.  Similarly, there should be no moves to restrict what is free at the point of use on the NHS. There are already worrying plans in parts of the English NHS to scale back crucial services that make a real difference to people lives, such as bariatric surgery for weight loss, dermatology, rheumatology, hip and knee replacements. Recent research from charities has revealed increased rationing of cataract operations across the NHS as finances deteriorate[8], and that provision of free IVF on the NHS in England has fallen to its lowest level since guidelines were introduced in 2004.[9] Yet evidence suggests that the introduction of charges is counter-productive and unfairly penalises those with poor health on lower incomes. For example, the Barker Commission found that “most options for charges seem likely to raise administrative problems and the risk of adverse impacts, which make them unattractive”.[10]

11.  In terms of the realism of the current funding envelope for the NHS, it is increasingly clear that the service is approaching a state of financial meltdown – if it has not reached that stage already. Health staff have been warning about impending crisis for months, and now the heads of NHS trusts are cautioning that the service is close to collapse.[11] The NHS ended the last financial year with an official deficit of nearly £2.5bn, although most experts think the true figure was closer to £3bn. On the surface the latest quarterly figures showed an improved situation, but this was only as a result of the extra money pumped in to trusts as part of the Sustainability and Transformation Fund. Providers are now routinely reporting their struggle to make ends meet with demand continuing to increase; the Royal College of Surgeons even referred to the pressures on the NHS representing a “perpetual winter of Narnia”.[12]

12.  The government’s headline decision in the last CSR to front-load a significant slice of the promised extra £8bn for the NHS in England was certainly preferable to leaving these increases until later in the Parliament. However, this extra money needs to be put in context. As the Health Foundation has pointed out, the total health budget is rising by £4.5bn in real terms up to 2020, an increase of less than 1% a year above inflation – this means real terms health spending per person will be around the same in 2020 as it was in 2010, despite the pressures exerted on the system by an ageing population and the costs of new technologies and treatments. The CSR means that the share of GDP going on healthcare will be just 6.7% in 2020-21, down from an already very low figure of 7.3% in 2015-16. [13] Parliamentary figures show the NHS funding settlement during the last Parliament was the most austere in its history, with funding growing by just 0.9% over the last five years[14], and this figure is set to be the average yearly increase for the whole of the 2009/10 – 2020/21 period.[15] When this is placed in the international context, the picture is even bleaker with health economists pointing out how the UK has fallen further behind other European countries, and is now ranked thirteenth out of the original 15 EU countries.[16]

13.  Moreover, while NHS England spending may have been protected, the wider Department for Health budget has been cut by 25%, which will mean less money for public health and the operation of arm’s length bodies such as Health Education England (HEE) and the Care Quality Commission (CQC). The capital budget will be frozen in cash terms over the five years of the spending review period too. In the words of the Health Foundation, “the Spending Review has substantially redefined and shrunk the scope of NHS services to be protected from reductions in spending”.[17] The CQC has had its government grant cut by 25% over four years[18] and public health spending will be cut by 4% a year in real terms. This is likely to prove highly counter-productive, as a failure to tackle issues such as obesity and sexual ill health stores up future costs for the wider NHS. There have already been warnings that cuts to sexual health services will lead to an “explosion” in infections.[19]

14.  A further reason to doubt the impact of the extra spending on the NHS is the £22bn of so-called “efficiency savings” which the service is expected to make, but which no one in the NHS seems to think achievable.[20] The vast majority of savings over the last Parliament were made by freezing staff salaries and squeezing the tariff for the amount paid to hospitals for procedures[21], but neither of these is a sustainable option for the future. It has become increasingly clear that there is little obvious left to cut in the NHS; the National Audit Office has pointed out that it is getting harder for trusts to make efficiency savings, with a 7% reduction in planned efficiencies made in 2014-15 compared to the previous financial year.[22]

15.  It is abundantly clear therefore that the current funding envelope for the NHS is insufficient. But the situation in social care is far worse. Councils have shouldered more spending cuts than the rest of government, with central government funding for local authorities having been cut by 37% in real terms over the last spending period.[23] Even though care spending has been protected relative to other areas of council expenditure, estimates from within the sector are that – when demand increases are taken into account – local authority spending on adult social care has still fallen by nearly a third since 2010.[24] The cut in central government funding is only part of the story, as it is taking place at the same time as other budget pressures stemming from inflation and an increase in demand. By the time of the November 2015 CSR a shocking state of affairs had been reached in which spending on social care as a percentage of GDP was set to be barely more than a half of one per cent by 2020/21.[25]

16.  The consequence has been a fall of more than 25% in the number of people aged over 65 receiving community-based, residential and nursing care services, with much stricter eligibility criteria.[26] Nearly 400,000 fewer people were receiving social care last year than in 2005-06, and Age UK has shown that there are 900,000 older people who have unmet social care needs.[27] NHS England has suggested that pressure on local authority funding will see a widening gap between the availability of, and the demand for, adult social care over the next few years.[28] Following the CSR, analysts Laing-Buisson pointed to a “real and imminent danger” of a care home bed capacity crisis, with the sector closing more beds than it is opening for the first time since 2005, with a net loss of 3,000 across the UK last year.[29]

17.  The CSR attempted to begin addressing the funding problem by introducing the council tax precept, in which councils in England are now allowed to add an extra 2% to annual council tax bills to raise extra money to pay for adult social care. Unfortunately such measures are painfully inadequate. From the outset think tanks predicted that the proposal would fall well short of raising the £2bn a year by 2020 that government figures projected[30] and some in the sector warned that councils would need the power to raise council tax by more than 10% to plug the social care funding gap.[31] Subsequent analysis from the Strategic Society Centre has found that local authorities will still confront “significant shortfalls” in their adult social care budgets despite the precept and that the precept “cannot be maintained forever in its current form.” The many problems associated with the precept include the regressive effects of council tax among households; a perception of “blame-shifting”; and incoherence with the integrated care agenda and wider reform of local government financing. [32]

18.  In addition, although the plan is that poorer councils will get more Better Care Fund (BCF) money[33], the precept plan seems set to intensify inequalities in social care provision. There were already major problems with much of the north of England having seen bigger cuts to care spending than other regions in recent years.[34] And the fear when the precept plan was announced was that local authorities with high levels of council tax income could potentially increase their social care spending by much larger amounts than more grant-reliant authorities through the precept.[35]

19.  The CSR confirmed the continuation of the BCF as a means of boosting the integration of health and social care services, with £1.5bn of extra money announced. However, only £700m of this is new money with the rest coming from the “new homes bonus” and it seems that the bulk of this funding will be held back until the second half of the current Parliament, with the BCF frozen in real terms in 2016-17 and apparently worth just £100m in 2017-18.[36] In common with UNISON, other bodies such as the Local Government Association and the County Councils Network have called on the government to “front-load BCF with additional funding from 2017/18 in a similar manner to NHS funding”.[37]

Workforce

20.  UNISON has long pointed to the folly of government attempts to restrict the supply of overseas healthcare staff to the UK. At a time when there are serious shortages in a number of professions, the NHS needs all the help it can get. UNISON therefore welcomed the decision of the Migration Advisory Committee to keep nurses on the shortage occupation list. Unless the current nursing shortage is addressed this will need to remain the case for the foreseeable future.

21.  The situation will not be helped by the UK leaving the European Union. Around 50,000 EU citizens work in the NHS and a further 84,000 in social care. The Social Market Foundation has estimated that almost 90% of EU nationals working in the public sector are unlikely to meet the current visa rules under Brexit.[38] Issues such as work permit problems, a tougher migration regime and passport difficulties seem likely to deter others from trying to come to the UK to work. In the past two years thousands of EU nurses have been recruited to the NHS to cover gaps in staffing. Any further reduction would place even greater pressure on services and staff.

22.  Post-referendum there is much uncertainty for Europeans working in the NHS and social care which, unless it is addressed, has the potential to drive staff away from our crucial public services at a time when they are needed most. UNISON is part of the recently convened “Cavendish Coalition”, and as such is calling on the government to make a firm commitment to EU migrant workers currently working in the NHS (and in other sectors) that they should be permitted to remain in the UK.

23.  A timely report from the International Longevity Centre warned that, with more than 90% of EEA migrant workers currently working in social care not holding British citizenship, any changes to migration policy resulting from the EU referendum could have serious implications for adult social care and exacerbate current recruitment and retention issues in the sector.[39]

24.  Below UNISON tackles a variety of issues – specifically those on pay, pensions, the NHS bursary and apprenticeships – that affect the future ability of the NHS to recruit and retain the necessary level of healthcare staff.

25.  Staffing shortages and the mounting agency bill all point to the fact that the government’s policy of pay restraint in the NHS is no longer sustainable. The Five Year Forward View contained a welcome admission that NHS pay would have to increase and “stay broadly in line with private sector wages in order to recruit and retain frontline staff”.[40]  Between 2010 and 2016 over £4.3bn has been cut from NHS staff salaries. This means a loss of between 12% and 19% of their real value since 2010. This has coincided with a growing recruitment and retention crisis for key staff groups. For example, the Public Accounts Committee recently reported that the proportion of nurses leaving their jobs increased from 6.8% in 2010–11 to 9.2% in 2014–15[41]. The removal of bursary funding for healthcare students and the impact of Brexit on the supply of staff to work in the NHS are set to make a bad recruitment situation even worse.

26.  The government also plans to raid the measly 1% a year paybill provision it has made for general staff pay rises in order to fund NHS implementation of the statutory minimum wage for those aged 25 and over (the so-called “national living wage”). Expecting staff to accept an award of less than 1% in order to pay for an unfunded Treasury commitment will only drive even more of these staff to the exit. UNISON believes that tackling low pay in the NHS is critically important and must be properly funded through a sustainable living wage policy, while recognising that staff at all levels of the NHS need a fair pay settlement. NHS staff in Scotland and Wales currently have the peace of mind that comes from the Living Wage commitments made by their devolved governments. Meanwhile, in England and Northern Ireland the lowest paid NHS staff continue to struggle on poverty pay. Far from matching the Living Wage, the lowest pay points in England, for example, are set to be overtaken even by the projected statutory minimum wage for those aged over 25 by 2018/19. UNISON wants to avoid the NHS pay structure being dragged down to the legal bare minimum. The lowest pay scales need to be restructured to build in a sustainable Living Wage commitment for the whole of the NHS. Tackling poverty pay is essential to ensure the NHS can attract and retain the staff it needs to deliver quality patient care, and keep morale and motivation high.

27.  The NHS Pension Scheme remains a key element of the overall reward package for NHS staff and is another element which, if undermined, has the potential to affect future recruitment and retention in the NHS. Over the past year there have been a number of worrying developments that, if sustained, could threaten the long term viability of the NHS Pension Scheme. A combination of NHS funding and recruitment and retention issues has seen two NHS trusts – Oxleas NHS Foundation Trust and East and North Hertfordshire NHS Trust – offer enhanced salaries to certain groups of staff in exchange for leaving or opting out of the NHS Pension Scheme. With many NHS organisations faced with similar situations it is likely this cost free approach to solving recruitment and retention problems will become more frequent, which in turn has serious implications for the long term viability of the pension scheme.

28.  Further to this, a number of government-led initiatives have seen the employer and employee costs associated with the NHS Pension Scheme increase. The introduction of the new State Pension from April 2016 ended contracting out and increased national insurance costs by 3.4% for employers and by 1.4% for employees. It is also expected that from April 2017 the scheme administration charge will be passed from the Department of Health to individual employers. Initially, the additional cost is projected to be 0.08% of pensionable pay.

29.  In July 2016, the Government confirmed that it would be going ahead with its plans to remove the NHS bursary and replace it with tuition fees and loans. London Economics calculated that the replacement of student maintenance grants with repayable loans, as well as the introduction of tuition fee loans, may result in a 71% increase in the cost borne by a representative student/graduate completing a three year degree in nursing, midwifery or the allied health professions; with an increase in cost comes a drop in demand.[42]

30.  The government argue that this drop in demand will not be felt because there are currently far more people wanting to do the courses than places available. In 2015, UCAS data shows that there were 186,260 applications for nursing courses, including midwifery. (However, according to UCAS, there are 4.41 applications per applicant, which suggests that the number of unique applicants is closer to 45,000.) From a recent Freedom of information request made to higher education institutions, UNISON understands that 17.8% of applications in nursing, midwifery and the allied health professions are assessed as having come from applicants meeting the eligibility and suitability criteria, and who would have been offered a place. This means that only 33,154 applications would have met requirements in 2015.

31.  Moreover, the crucial question is how sensitive applications are to changes in price. London Economics argue that it is probable that applications are more responsive to increases in price than actual participation in higher education. We also know that following the introduction of £9,000 fees in 2012 (an increase in costs of approximately 10%) applications declined by 10% the following year. Five years later, applications from English domiciled students were still 3-4% lower than in 2011. This suggests that the elasticity of applications is anywhere in the region of -0.3 to -1.04. If one takes the middle of this range (-0.5) as a starting point, it implies that a 10% increase in the cost of undertaking a degree will be associated with a reduction in applicants by 5%. Using London Economics’ analysis relating to the expected price increase, this implies that the 71% increase in price would be expected to reduce the number of applicants by approximately 35.5% - leaving just 21,384 suitable applicants (66 fewer than in 2015).

32.  The government claim that removing the bursary will create 10,000 additional training places by 2020. It may be the case that universities will be able to offer more course places but, as the estimates above indicate, there will not be the students to fill them unless universities drop their entry requirements – something that UNISON and patients would not be able to support. There is therefore a very real risk that these changes will exacerbate current shortages and have serious consequences for patient safety, as it will become more difficult to maintain safe staffing levels with fewer nurses, midwives and allied health professionals coming through the training system.

33.  Employment of apprentices in the NHS continues to grow with policy commitments in all four UK administrations to increase the number of apprenticeships in the economy generally, with an expectation that the public sector will lead by example. From April 2017, employers with paybills over £3m will be required to pay 0.5% of paybill into the government’s apprenticeship levy. In England alone the levy will extract £200m a year from the NHS and there is considerable concern that, due to the current mismatch between skills shortages and availability of apprenticeships, the NHS will not in the first years be able to recoup all this money. It is expected that any funds unused by NHS employers after 18 months would be redistributed for use by employers in other sectors. This is a particularly perverse prospect in view of the financial situation in the NHS.

34.  There is concern about the distorting effects of the imperative for employers to recoup the maximum, and the knock-on impact on recruitment and retention. This is driving some employers to convert all vacancies in Bands 1-4 of Agenda for Change into apprenticeships with no strategic approach – and no assessment of suitability, the capacity among other staff to support apprentices, or the impact on retention of staff recruited as apprentices. Many employers are looking to divert money currently in their learning and development budgets to meet their levy payments. This will leave a shortfall in funds to support planned learning with particular implications for the provision of continuing professional development as this cannot be funded through apprenticeships. Such short-termism may also mean existing staff not receiving the training they need unless it can be shoe-horned into an apprenticeship programme.

35.  In England the effects of the levy on the NHS will be compounded by considerably increased targets for apprenticeship starts which will now be set at individual employer level. The government has consulted on statutory targets for public sector employers for the number of apprentices they start each year – to be set at 2.3% of each employer’s headcount.  Across the NHS, this will add up to a target of 28,000 starts per year. In 2015/16, Health Education England reports that there were nearly 20,000 starts. The concern about a crude approach based on starts per year is that there is a considerable disincentive for employers to consider investing in higher value apprenticeships which last longer than a year. This is because the employer can only count them as a “start” in the first year but must continue to invest the resources needed to support them through their whole apprenticeship.

36.  Currently there are few apprenticeships available in the areas of greatest clinical shortage. An employer-led “Trailblazer” group is now working on developing a nursing apprenticeship but this is expected to take another couple of years. There may be similar developments for allied health professionals but again these will not be available in the short-term. As a result, the primary focus of apprenticeship development has been in Bands 1-3 with some provision for Band 4 roles. HEE data shows that the majority of apprenticeships in the NHS are delivering at educational level 2 – equivalent to GCSE A-Cs. It is far from certain whether there will be an appetite from NHS employers to invest in degree-level apprenticeships in the NHS, even if more do become available. This reflects in part the short-term one-year target cycle for starts, and also the uncertainty over the effects of the removal of the student bursary. As the levy only pays for training and assessment but not for salaries there will be further pressure to drive down wages of apprentices in order to make up for the levy outlay, and as a more general means of cutting paybills.

37.  The current situation in the ambulance sector illustrates how failings in workforce planning, problems around recruitment and retention, and issues with skill mix are affecting staff and the quality of service they provide to patients. Changes from vocational training to reliance on higher education, coupled with a period of poor workforce planning, has led to a critical shortage of trained paramedics. Despite attempts to recruit from overseas, the vacancy rate has remained stubbornly high (around 10%, with regional variations). One of the problems facing ambulance services is the gap between paramedic leavers and the number of new graduate paramedics qualifying from university. Key retention issues for ambulance staff are pay and grading; operational pressures, such as demand on 999 services, shift over-runs, lack of adequate breaks; and health and wellbeing issues such as work-life balance, stress, ill health, violence and aggression. Investment in vocational training to convert existing ambulance staff to paramedics would provide a way to rectify skill mix problems.

38.  Paramedics have an adaptable skill mix enabling them to deliver a range of responses to patients. However, current time-based performance measures limit the innovation ambulance services are able to make by selecting the right skill mix for the patient. The Ambulance Response Programme, led by NHS England, is the first attempt at looking at how to send the right response to the right patient and Wales now has a clinical model that is showing promising results. Currently, paramedics are being poached from ambulance services to work in minor injury units, GP surgeries and the private sector, as they have a very wide set of assessment and clinical skills.

39.  There are even more pressing issues concerning the social care workforce. UNISON’s recent submission to the Communities and Local Government Committee[43] covered the most significant of these: there is inadequate funding for hourly rates and a glaring failure to tackle non-compliance with the National Minimum Wage (NMW), with non-payment endemic in the sector; less than a quarter of councils in England and Wales make it a contractual condition for care providers to pay for workers' travel time, the main reason for NMW non-compliance; illegally low pay rates fuel staff turnover and send out a message that care workers do not deserve to be respected for their work; and the focus on personal budgets has produced further insecurity for those employed through direct payments, who may find that their employment rights are not properly observed. Several of these concerns were brought in to sharp relief in September 2016 by UNISON members taking a case against the care contractor Sevacare and Haringey council over their failure to receive the minimum wage.[44] An estimated 160,000 to 220,000 direct care workers in the UK are paid below the national minimum wage.[45]

40.  In terms of a practical measure for countering some of this abuse, UNISON has been encouraging councils to improve the delivery of their homecare services by adopting the union’s Ethical Care Charter.[46] The Charter was designed as a simple way for councils to improve homecare standards for both the vulnerable people they are responsible for and for the workers who provide care. The Charter is a set of commitments that councils make which fix minimum standards that will protect the dignity and quality of life for those people and the workers who care for them when they commission their homecare services. The commitments include ensuring that there is continuity of care, ending 15 minute visits for personal care, paying staff a living wage and ensuring that they are paid for their travel time.

41.  Eighteen local councils in England, Wales and Scotland have now adopted the Ethical Care Charter and UNISON expects the number to continue to increase in the coming months. The Charter has already had positive results for both care workers and care users. Southwark Council was one of the first councils to adopt the Charter and they carried out an evaluation of the performance of their homecare services since then.[47] They found concrete evidence of an improvement in service, based on staff recruitment and retention rates, take-up of training, and service user outcomes. Islington Council, which has also adopted the Charter, had similarly positive feedback. As well as witnessing improvements in the morale of homecare workers, providers commissioned by the council also reported significant improvements in staff retention rates since the Charter was implemented.[48] One of the private providers commissioned by Islington Council pointed to notable improvements in staff well-being as a result of higher wages. Prior to introducing the London Living Wage turnover amongst its staff averaged over 10% but now it is less than 3%. The policy director of the provider stated that “retention and recruitment – serious struggles in social care – improved dramatically. Care workers became more motivated and so became more reliable, supportive, happier and healthier – all of which directly benefits service users...stable, reliable, high quality care services deliver improved outcomes for individuals and save the health and care system money.”

42.  UNISON is in the process of carrying out a more detailed evaluation at a larger spread of councils to gauge the impact of the Charter. The union is hopeful that the results will be used to encourage more councils to adopt the Charter. The success of the Charter to date shows that in order for care standards and outcomes to improve, steps must be taken to improve the terms and conditions of the workforce. 

Models of service delivery and integration

43.  The integration of health and social care services is something that has long been sought by various governments and those involved in delivering care. UNISON has adopted a position of support for the principles of integration, but with a number of important caveats: integration should only proceed on the basis of full staff and patient / service user involvement; it should not be used as a cover of cuts; and, where it involves integrating workforces from the NHS and local government, integration should harmonise upwards rather than level down terms and conditions.

44.  Any merging of two models of care with such different funding models is bound to create concerns about bad practices from one seeping into the other. There is a need to ensure that no element of means-testing in social care is allowed to creep into the NHS through such a process. Equally, there are staff concerns about the track record of local authorities in contracting out social care services to the cheapest bidders at the expense of quality, and the driving down of fees which has contributed to the downward spiral in employment conditions, as outlined above.

45.  Moreover, there is a need to challenge the somewhat lazy assumption that integration will automatically bring about substantial cost savings. To begin with, integration is not something that can be attempted overnight; in the oft-quoted case study of Torbay for example, it took the best part of a decade for service integration to take shape.[49] There is no particularly convincing evidence about the amounts of money that integration can be expected to save, and in the short term there should be an expectation of increased funding to pay for things such as double-running costs and re-training. A recent Health Service Journal investigation found no evidence that integration would lead to significant savings[50] and pointed to international case studies which found that, although there were better outcomes for patients, there was no evidence of reductions in hospital admissions or improved cost effectiveness.[51]

Submission produced by the UNISON Policy Unit

23 September 2016