The Covid-19 crisis has highlighted the critical role of care workers and made it obvious that this overwhelmingly female workforce deserves far better pay and conditions, with over 100,000 current job vacancies illustrating the chronic lack of attractiveness and recognition.
But how does a sector facing such a massive increase in demand and costs, with 400 bankruptcies already in the last five years, ever fund and deliver a significant pay increase?
Pay expert Duncan Brown sees two potentially workable solutions. Either move care workers onto the NHS Agenda for Change pay system. Or build the type of infrastructure that we have seen established for social workers to raise the status of the occupation, then encourage and require employers to implement ‘good work’ and improved pay and conditions.
As the UK’s latest grim mortality statistics highlight that the ‘death toll signals the extent of the care home crisis’, many of us will have nodded in agreement with the Observer’s headline last Sunday: ‘When it comes to care workers, don't just applaud, pay them’.
Secretary of State for Social Care, as well as the NHS, Matt Hancock reminded us that we are banging our dustbin lids every Thursday evening to acknowledge and thank our brave front-line care workers, in this Cinderella of a service, and not just our equally amazing hospital staff. He announced earlier this month the award of a new badge to recognise them, a ‘unifying symbol of pride in our social care champions’.
Perhaps it will at least help those that have been turned away from some supermarkets for, as they saw it, impersonating keyworkers. But I doubt it is at the top of their wish-list right now. Or even higher pay. Right now that must be addressing the PPE shortages, which are reportedly leading some to resort to bin bags to protect themselves from the obvious dangers of infection in caring for residents.
The 7,316 deaths recorded in care homes in the week to April 17th (according to the ONS’s latest stats) represents a doubling every week since the start of March, is still growing and seems set to surpass those occurring in hospitals. The Chief Executive of the NHS Confederation, the umbrella body for employers, described the statistics as ‘deeply alarming’ and went on that ‘we need to do everything we can to support the care sector’.
A new coronavirus strategy for adult social care was belatedly published late last week, promising new systems to distribute protective equipment and wider access to testing for residents and staff, after outcries from homes. Providers are now mostly in private sector ownership, delivering a vital public service which has become so visible in this crisis, but are still funded in the main by local authorities.
It was too late though for Carol Jamabo, a 56 year old mum of two with an ‘uplifting, joyful and enthusing personality’, a keyworker for 25 years who had been working for Cherish Elderly Care in Bury and became the first care worker to die from catching the virus on 1 April. The £4,500 cost of her funeral was raised for her family in less than 24 hours on the Go Fund Me charity website.
Once this horrendous virus has peaked and hopefully left us, retired consultant Dr Kirsty Muirhead echoes the views of many of us in her letter in Financial Times last week on the need ‘to respect and value carers, not just by applauding them, but by supporting their training and by increasing their pay’.
Care work and the workforce
There are 223 NHS hospital trusts in the UK but some 18,500 care providers across 39,000 locations. According to Skills for Care, approximately two million people work in care jobs, with 1.2m adult social care workers, 465,000 in care and nursing homes, 610,000 providing care at people's homes like my parents, and 150,000 providing day and community care. The workforce is overwhelmingly female and 50% more likely to be from a BAME background than other workers. For example, a study by the charity promoting economic development for women in Wales, Chwarae Teg [LW1], shows that there are nearly 20,000 care workers in Wales, of which some 80% are women and 50% over 40 years old. In London, meanwhile, 81% of care staff are women, their average age is 45, 24% are aged over 55 years, and 67% are black or ethnic minorities (BAME).
How these jobs and the work they do has been classified by the Government throughout the Brexit negotiations as ‘unskilled’, and so are still excluded from entry under the latest immigration proposals published earlier this month, defeats me. Care workers help my mum get up and dressed every morning. They give my dad his bath and a shave. Their work requires kindness, tolerance, generosity, compassion and intelligence. It typically involves specialised tasks, from coping with seizures to administering medicines. They often work long, arduous hours.
Throughout this crisis, they have been there, moving in at some care homes, sleeping in caravans in the grounds of others. With the rising death toll, they are helping people say goodbye to their loved ones. They fill their residents’ rooms with mementos and photographs. They hold their hands when there is no one else to do so – ‘their commitment to vulnerable people goes above and beyond’. It always has done, but now the country as a whole is belatedly realising it.
And in return, how have we chosen to recognise and reward these essential, often remarkably committed keyworkers? Appallingly badly. Research published last weekend showed that most are paid the National Living Wage (NLW), with more than half earning less than the ‘real’ living wage set by the Living Wage Foundation (£9.30 per hour, or £10.75 in London).
The rising level of the NLW has helped, with the Government sensibly still going ahead with the already announced 6.2% increase at the start of the month, bringing it up to £8.72 per hour for over 21s. But research for the Low Pay Commission shows tens of thousands of the low-paid miss out even on this legal entitlement and other benefits, such as holiday and sick pay, a key focus hopefully for the planned, more powerful single labour market enforcement body under Matthew Taylor.
Each year Skills for Care publishes a report, The state of the adult social care sector and workforce in England, in which the scale of the current poverty-pay situation and the recruitment and retention challenges this creates are laid out. The introduction and escalation of the NLW has indeed stimulated noticeable improvement in starting pay over the past seven years: from an average of £6.78 an hour in September 2012 to £7.89 in March 2018 and likely to have risen further since.
However, this increase hides a much less cheerful picture in reality. As all other sectors have had to meet the NLW commitment, this increase has not made pay for social care work any more attractive. For example, the average hourly pay for care workers is below the basic rate paid in most UK supermarkets. Staff are also lost to similar, better remunerated roles in the NHS.
In order to meet the NLW requirement for starting pay, hard-pressed social care providers have held down their overall paybills in other ways. An increasing proportion of the workforce is now paid at or around that minimum level. The pay differential between care workers with less than one year of experience and those with more than 20 years has reduced to just 15p an hour. Many are also no longer paid for their travel time, which is significant in London.
It is not like we offer security in exchange for the low pay – care workers are four times more likely to be on a zero-hours contract than the rest of us, representing, for example, 56% of care workers in Wales. Professor Sian Moore of the University of Greenwich, in her research for the Low Pay Commission, found examples of home care workers being electronically tagged, like warehouse workers and delivery couriers, so that they can be paid only for every 15 minute segment of work – if they turn up and their patient is out at the shops, they don’t get paid.
A social care worker, Bob, told Professor Moore’s team that his schedules are sent to his mobile phone at only a day’s notice because of staff turnover. Even more worryingly given the current situation, this study found that ‘a number of directly employed (care) workers were unclear about holiday and sickness entitlement and there was some reluctance to take holidays, particularly sick leave, [on the basis of] a perception that asking for or taking leave risked eliciting punitive action from employers’.
Councils and the NHS only pay providers for care actually delivered. They will not pay for care workers who are prevented from working, for example because they are self-isolating. So what would you do if you were a care worker and started to get a sore throat? Follow the Government’s direction to stay at home for a week and self-isolate, or prioritise feeding your kids and go into work?
And my description of poverty pay is no exaggeration. As former HR director and co-founder of the Financial Inclusion Alliance Norman Pickavance points out in People Management, ‘many of the keyworkers we are applauding as heroes hail from a growing band of working poor. The majority of the UK’s poor today and children in poverty are in working families’. This has driven the growth we have seen well before this pandemic in the use of foodbanks, pay day loans and debt advisory services.
The Institute for Fiscal Studies has been looking at the initial effects of the virus on employment and earnings. It found that women and young people in so-called ‘low skill’ jobs were already getting hit disproportionately hard, with the crisis shining a ‘spotlight on the problems of fragile employment practices, gig working, debt and the exorbitant cost of housing, childcare and public transport’.
The Government says it aims to recruit 20,000 extra social care staff over the next three months to help cope with the pandemic, with over a quarter of staff in some homes having to self-isolate. Good luck. Staff shortages are nothing new here. The care sector has always struggled to recruit enough staff because of its justified reputation for low pay and lack of recognition. Skills for Care estimates that there are currently 122,000 FTE vacancies in England. Turnover rates even before the crisis averaged 31% for adult care staff.
Increase their pay! But how do we afford it?
So like me and Dr Muirhead, you probably feel the solution is obvious: pay them more!
But, as others have highlighted, the pandemic has been preceded by a vicious pincer movement in social care of growing demand from an ageing population and chronic underfunding. Since 2010, councils in England have had the money they receive from central government cut by nearly half, as part of the government’s austerity measures after the last economic crash in 2008/9. Some of that loss has been offset by increasing local taxes, but the amount councils can spend on all the services they provide has been cut by almost 30% during that time. The Government says that councils’ access to additional dedicated funding for adult social care increased to £3.6bn in 2018 and £3.9bn in 2019/20. But it was over £5 billion in 2010.
Ian Hudspeth, chairman of the Local Government Association’s community wellbeing board, said last week: “Social care as a whole has been desperately underfunded for decades and we have been consistently calling for a cross-party consensus on the future of care and how we pay for it, [since] long before the coronavirus crisis”. And the biggest portion of any care home’s costs? That’s right, staff – typically representing over half of their total outlay.
There are concerns that significant numbers of care providers may not survive the crisis, according to the UK Home Care Association, even at current levels of pay and without the additional pressures and costs of the virus. They are facing further demand for beds after NHS England’s recent decision to discharge long-term patients who are medically fit, as part of efforts to free up 15,000 hospital beds. Even before the pandemic, over 400 had gone out of business in the last five years in this ailing sector, with debt-fuelled business models having become a common feature in the sector post-privatisation.
Four Seasons Healthcare, a dementia care specialist provider with 322 homes, which employed 22,000 people and had 17,000 residents, collapsed into administration in 2018, following attempts to run it profitably by a succession of owners, including Guernsey-based private equity group Terra Firma and Qatar’s sovereign wealth fund. As part of its protracted wind-up, 44 homes were transferred to rival operators in an agreement last month. The GMB trade union’s National Officer, Rachel Harrison, labelled the transfer a ‘care catastrophe’ that reflected the Government’s ‘appalling lack of strategy’ on social care.
But whatever the rationale for a significant pay increase for care workers, it seems unlikely that many care providers or councils could afford to fund it under current financial restrictions. Although the Chancellor, Rishi Sunak, unveiled a £350 billion emergency economic package to support ‘small and large’ businesses, for which care providers can apply, the Government was forced to announce last Friday that councils across England will receive a further £1.6bn to deal with the immediate impacts of coronavirus, taking their total pandemic funding to more than £3.2bn. But even before the crisis, the Labour party claimed that social care would require an extra £8bn to stabilise the system.
Squaring the Value/Cost Circle
So can any significant improvement in pay and conditions, however justified and deserved, be funded and delivered by the UK’s cash-strapped, demand- and cost-pressured, staff-short local authorities and private providers, especially in any sort of practical time-frame which might help address the immediate crisis?
It took over five years, for example, to develop and implement the NHS’s Agenda for Change job evaluation and pay system in the early 2000s for a similar size of workforce. The move to ‘single status’ in local authorities at around the same time promised an uplift in pay for care and other female-dominated jobs in the lowest grades, but even then, a variety of obstacles including funding prevented this being realised in practice in most councils. And with their current financial plight, some homes are talking of having just five weeks left to survive.
Based on my experience of methods of valuing roles for major workforces, including the Civil Service, Armed Forces, Doctors and Dentists and judiciary, I see two viable and practical ways forward for care workers.
1. Move care staff onto the NHS’s Agenda for Change pay and career structure
First, we could move the social care workforce onto the NHS Agenda for Change (AfC) pay structure. The decision as to the best structuring of public and/or private ownership models for social care is one that is way above my pay grade. But highlighting the complexities and inconsistencies in health and social care, the Local Government Association believes that ‘our care model must change so that people experience it as a seamless package of care and support’. Given the overlaps in staffing already between both sectors, for example for registered nurses, then particularly if the integration of NHS and local authority budgets and services that we are seeing in large metropolitan areas such as Manchester and London continues, integrating workforce planning, HR, pay systems and terms and conditions across health and social care surely makes sense too.
An example is the Lincolnshire Talent Academy, which has developed a common shared goal of recruiting local talented staff across NHS, social care and the third sector. More joined-up thinking on the workforce in this way should and will almost certainly lead to pressure for greater harmonisation in pay and conditions.
Covering all one million-plus NHS employees bar the medics, Agenda for Change had two primary aims when it was introduced 20 years ago: first, to establish a logical, fair and consistent approach to base pay management right across the service; and second, to help to address skill shortages by providing more competitive pay nationally and by acting as the foundation for a ‘skills ladder’ of career and pay progression, so as to provide internal resourcing of higher-graded staff through promotions.
A friend’s weekend cleaning lady, Veena, perfectly illustrates its success. Having been supported to train and qualify, Veena, who started out as a healthcare assistant when her kids were young, will - once the pandemic is over - move into a Band 5 role (the core nursing grade), helping the NHS to address its own staffing shortages and meaning Veena can afford to give up the additional cleaning job. By contrast, most care assistants have nothing like these career and pay progression opportunities at the moment, with many working in small care homes, each recruiting independently and many not investing at all in staff training and development.
The NHS job evaluation system, which determines which pay band jobs are placed in, should be perfectly able to accommodate social care jobs without any modification necessary. It already, for example, covers all health, social care and government service staff in the States of Jersey, where pay is fully integrated across the public sector. It was originally developed to measure the medical workforce as well. The forthcoming report from the review of the gender pay gap in medicine, led by Professor Carol Woodhams and Dame Jane Dacre, I understand, is likely to include recommendations to apply this job evaluation system to medical staff and to shorten lengthy consultant pay scales, bringing their pay systems into closer alignment with AfC and hopefully thereby helping to reduce the gap.
Once on the pay structure, then the integration and funding of improved benefits for care workers up to NHS levels could also be considered and possibly phased in over future years, so as to ease the funding costs. The Kings Fund estimates that the social care workforce would need around £1.7 billion of investment to match the recent NHS pay deal, which now seems relatively modest compared to some of the other coronavirus spending investments. According to the IPPR report Fair Care, ensuring all social care workers are paid at least the real living wage (excluding London) would require an additional £340 million. The Office for Budget Responsibility’s current forecasts, for example, are that 30% of the UK workforce could be furloughed for up to three months, at a cost to the Treasury of £42 billion. An extra £2 billion therefore would seem to be money well spent; and certainly well deserved.
You could argue very logically that a national, job evaluated pay structure should be developed for the care sector itself, in the way that occurred for example, for school support staff who were formerly paid whatever each individual schools decided. And some occupations and groups in the sector would probably hate to see themselves coming under the auspices of the NHS.
But this would be a major exercise, likely as with Agenda for Change, taking considerable financial resources and years to design, test and implement. Going back to local authority terms and conditions, another possible alternative, would probably be a political step too far and seen as a retrograde move in many quarters.
The NHS structure is far from perfect, but it is tried and tested. Irrespective of the question of public or private ownership in the care sector, if the direction of travel is towards a more integrated health and care service, then it could be argued that this is a forward-looking move.
2. Encourage Voluntary Action within a National and Regional Framework of Good HR and Reward Practice
A second alternative would be to reflect recent research and learning on the business case for and best methods to deliver improved pay and conditions, and especially in the local government sector, on the approach adopted in recent years for social workers. This would involve much more strongly requiring, encouraging and supporting individual employer actions on pay, within the framework of a national plan to improve the standing, skills and careers of the occupation.
A decade ago, social work suffered from many of the issues facing care workers today: poor pay and perceived attractiveness leading to major staff shortages, which additionally in London and the South East drove a counter-productive and expensive bidding war between authorities, with ‘golden hellos’ and special benefits.
In response the Department of Health and Social Care published in 2016 and since then has been progressing a five-year strategy for adult social care, ‘Our vision for a highly skilled, capable and confident profession’. Actions have included:
- Developing social work as a valuable and recognised, single profession, with a common core set of values, skills and knowledge.
- Establishing a dedicated regulator for social work focussed on raising the quality of education, training and practice.
- Ensuring a sustained focus on continuous professional development to support retention and progression and more widely increasing funding for social work education.
- Improving the support offered to newly qualified social workers.
- Setting national standards for specialist and advanced roles in social work with adults.
Employers have responded in a variety of ways to this more positive context for both adult and children’s’ social workers. The London boroughs agreed a Memorandum of Understanding on Working Together to Improve the Workforce of Children’s Social Work Professionals updated last September, including:
- A commitment to cap agency worker rates and encourage permanent staffing.
- Working together to promote positive images of children’s social work and to promote careers in social care through press, social and other media and advertising.
- A range of initiatives for increasing the supply of high quality, permanent staff.
- Aligning and improving pay rates.
A similar agreement now covers adults’ services in London.
Improved career development and progression opportunities are evident in many individual councils. Lincolnshire Council’s children’s services for example, has seen improvements in the quantity and quality of internal applicants for management roles following the introduction of its Bridging the Gap course, in which social workers with potential management ability are offered specific skills training to improve their ability to take on a management role, when one becomes available.
Common in the NHS, but much rarer in social work, is the role of clinician-researcher, with dedicated time spent on a specific research project in their field or for their service. Lincolnshire also gives practitioners on their Bridging the Gap programme the opportunity to undertake small-scale research projects on a topic of their choice, to reconnect them with the latest research.
Cornwall’s children’s services have developed an advanced, consultant social worker role, paid at the same level as a team manager. Applicants are expected to be experts in niche and specific areas of practice. There is no restriction on the number of consultant social workers who can be appointed, provided the threshold of experience and learning has been met, reflecting a similar model that we see applied nationally to help to promote and retain teachers.
Could something similar be developed and applied for care workers? Perhaps more of a national training, career and pay framework could be developed, so as to encourage improved people management in individual providers. Then care workers could see and be enabled and supported to progress into higher-skilled and paid roles across the sector, as occurs far more effectively in the NHS.
The Care Quality Commission (CQC), the integrated regulator across health and social care, could encourage and require aspects of the framework to be applied as part of its role in ensuring and raising care standards, in the way that the Financial Conduct Authority does for the much higher-paying banks. The improvement and professionalisation of care roles could be tied to the regular CQC inspections, with the identification of stronger inspection ratings and weightings allocated to training and good workforce practice, as a lead indicator of better care provision.
Higher Pay and Good Employment Pays Off
But even if the regulator were to require it, in such a dispersed sector we need to help individual providers to recognise that even under all of these care demands and financial pressures, improving the pay, conditions and prospects of staff is both possible and desirable. Even in the most cash-restricted contexts, investing in staff and especially low paid staff, really pays off for everyone – employee, employer and society.
Last year I researched and wrote up the story of Anchor, now Anchor Hanover, Homes, England’s largest not-for-profit provider of care and housing for older people with 54,000 homes across 17,000 locations, led by the inspiring Jane Ashcroft. As well as paying the real living wage and maintaining appropriate pay differentials above that level, Anchor delivers on its aim of being a great place to work through means including:
- An emphasis on training and internal promotions, with all staff having personal development plans
- A comprehensive benefits package
- Extensive employee involvement and communications.
The combination of high productivity and exceptional staff loyalty and engagement that results from this makes it a sustainable and affordable approach for Anchor.
Anchor is far from being unique. There are other care providers accredited by the Living Wage Foundation such as Heritage Healthcare in Tandridge.
Citizens UK, which helped establish the Living Wage Foundation, also helped in 2013 to set up the Social Care Campaign and the Social/Ethical Care Charter, a movement that predates most of these voluntary frameworks and campaigns for sufficient funding for better quality care provision, integrated health and social care services and a better deal for care workers. The charter calls for proper training for care workers, an end to 15-minute care visits; and care workers to be paid a real living wage that meets the cost of living and with paid-for travel time. Camden and Islington Borough Councils were the first two local authorities to support the movement, and over 50 local authorities are now signed up.
The London Mayor’s Good Work Standard and Andy Burnham’s Greater Manchester Good Employment Charter are similar but more broadly-specified voluntary initiatives providing well-designed frameworks and accreditation for all employers to commit to good work, pay and employment conditions. These include stable hours and permanent contracts, fair pay levels with a real living wage minimum threshold, training and career progression opportunities.
But whilst achieving growing support, the fact is these voluntary initiatives have had comparatively low levels of take up so far, especially in the lowest margin and lowest paying sectors such as care and retail. Even those local authorities signed up for them appear in some cases to be providing insufficient funding for the private care homes housing their residents to be able to afford to adhere to the charter.
So any substantial and rapid progress on low pay and insecure work is going to need at least improved co-ordination and resourcing; and probably also new national and compulsory initiatives and funding.
The ‘Good Work’ legislative agenda resulting from Matthew Taylor’s report should hopefully get a powerful shot-in-the-arm from the current situation, with the lack of employment protection for delivery drivers and others in the gig economy, as well as employees such as care workers on ‘one-way-flexible’ contracts, having been made painfully obvious.
The key question for us all is whether more is required and if so, how should we fund it? Should we accept the need for higher rates of taxation on employers, employees and the self-employed to fund improved security and care for our friends, colleagues and relatives (and down the road for ourselves), in the way that we see in economically successful countries such as Denmark? Chancellor Rishi Sunak hinted as much in announcing his multi-billion pound package of additional protection measures for the self-employed.
He also recognised, de facto, with the temporary relaxation announced for the crisis of restrictions on Statutory Sick Pay of £95.25 a week; and the temporary uplift in the basic rate of Universal Credit (£342.72 per month, paid in arrears after a minimum five-week wait), that this can hardly be regarded as an adequate safety net, in a supposedly modern welfare state and leading world economy.
Do we also need much tougher employment standards and enforcement as part of the ‘new social contract’ for employers and employees that many commentators have been calling for, as part of the ‘radical reforms to forge a society that will work for all’ that the Financial Times now believes is required? Contractual reforms might include:
- A right to a permanent contract after 26 weeks, rather than just the proposed right to request one;
- Removing the current, confusing ‘worker’ employment status; and
- Banning umbrella companies, rather than just better regulating them.
Conclusions: Pay up and skill up!
‘Too often, the funding of social care is seen as an economic and technical issue of raising the funding. The more fundamental questions are personal and philosophical: what sort of support would we want available if we needed care? How much do we value this, and how much might we therefore be prepared to pay for it?’
This is Professor Jon Glasby, Professor of Health and Social Care at the University of Birmingham, writing in the introduction to the Local Government Association’s Green Paper on the future of adult social care. Professor Glasby is also, in effect, asking how much we are prepared to pay for and invest in care workers. If ‘doing nothing (was) no longer an option’ for the LGA in mid-2018, it certainly cannot be the case today in the devastating midst of the coronavirus.
According to the renowned Professor of Epidemiology and Public Health at University College London, Sir Michael Marmot, on Twitter last weekend, the worst of the ‘inequalities exposed by the pandemic: (is) the scandal of under-paid care workers who perform such a vital role’. Low skilled workers no longer, but still low paid, this huge, largely female workforce has been transformed in the last month into keyworkers, highly valued by everyone in the community.
Skills for Care researched a sample of care providers with staff turnover of less than 10% to identify any common and differentiated patterns of employment practice. They found that working hard to attract the right people, with the right values, behaviours and attitudes to work in social care, was vital. It was also important to pay above the National Living Wage, but also to sell the wider benefits of working in adult social care and to provide good working conditions, especially flexibility.
But like Anchor Hanover, developing a positive organisational culture was perhaps the key differentiator, where staff are supported and valued and have opportunities to enhance their skills and knowledge, reinforcing the message that working in adult social care can be a good, lifetime career choice. As residential care provider Old Hastings House told the researchers, ‘maintaining high levels of staff motivation by supporting staff development, tackling performance issues, and developing a culture of shared ownership’ was their secret for high staff retention and quality care provision. Many more care providers need to be let into this secret.
IES’s own wider research on pay and career progression for lesser skilled workers across different sectors and countries suggests that even when subject to intense financial and pricing pressures, not investing in employees can be a false economy due to the increased indirect costs resulting from employee turnover and low staff satisfaction. We provide many good examples and a free employer toolkit to support implementation of pay and career progression for staff in these roles.
The low standing and public recognition of care work certainly seems to have shifted in a very major way in the last month. Whatever the funding and practical design difficulties, I believe that this presents a real opportunity to create one very positive outcome from this horrendous virus: better pay and career progression for care workers to support better quality social care. The Government, civil service, employers, trade unions, researchers and HR and reward professionals need urgently to get our heads and resources together and make sure this opportunity is taken.
Duncan Brown, PhD, MBA, FCIPD is an independent reward researcher, adviser and trustee with more than 30 years of experience. He is a principal associate at IES, visiting professor at University of Greenwich and co-author most recently of A Handbook of Reward Management (Kogan Page, 2019)