The residential social care sector is crumbling. There are insufficient staff to provide care and residents are already suffering, left alone in soiled clothing or without company for hours at a time and hospitals are consequently forced to care for older people long after the need for medical treatment has passed.
Care homes are failing for lack of good quality local staff. New government proposals to recruit cheaper staff from abroad to alleviate the pressures are perfectly designed to increase labour exploitation but without improving staffing levels or quality of care.
Spiralling energy bills this winter will exert more financial pressure on care homes, driving many out of business and raising care fees for residents, families and local authorities to even higher levels.
Impact of Brexit
Health and social care services have relied on immigrant labour from the 1950s onwards. Over the decades they have consistently failed to recruit, train and retain sufficient UK born staff and, even while the UK was in the EU and able to freely recruit from EU countries, social care was always highly reliant on care workers from further afield.
Prior to the end of the Brexit transition period 5.2% of all new starts in the sector were born outside the UK, after this it fell to 1.8%. However, the recruitment gap has not been filled by local people and has continued to grow.
In implementing Brexit, the government opted to constrain the capacity of UK employers to employ people from outside the UK, even though the Kings Fund warned this was unsustainable with a (then) vacancy rate of 5.4% and a 25% annual turnover of staff.
In October 2021 Steve Barclay, the current secretary of state for health but then minister for the cabinet office, proposed that Brexit Britain should use its new “freedoms” to promote the appointment of more British-born workers to stop the “damping down” of wages and promote “home-grown talent”:
“We must use our new-found freedoms outside the European Union to promote and champion our workers, rather than undercutting them with imported labour which dampens down wages and undermines the breadth of home-grown skills and talent.”
The current crisis
The House of Commons health and social care committee (HSCC), led by Conservative Jeremy Hunt published a report Workforce: recruitment, training and retention in health and social care on 20 July. It proposes that the health and social care sector is “facing the greatest workforce crisis in their history”. The vacancy rate in both is around the 100,000 level.
Since the end of the Brexit transition period, Skills for Care estimates that there has been a small percentage rise in the number of posts available (0.3%). This figure would and should be much higher if care home provision matched demand. In 2019 Age UK estimated that ‘social care delayed discharges’ cost the NHS £587mn a year and that they have a significant impact on the care that can be provided, not just for those who need hospital care but can’t access it, but also those who would be better cared for in a non-clinical environment.
Over 2021/22, the turnover rate of social care staff was 34.4%; there was a 3% drop in the number of vacancies filled and a 50% rise in vacancies. In other words, whilst the volume of beds is rising only modestly, the vacancy rate is rising exponentially year on year.
High vacancy rates increase the risk of staff burnout and subsequent turnover. Vacancies are increasing and posts are not being filled because staff can find less stressful and better paid jobs with regular and more social hours elsewhere. The big supermarkets now offer a wage of £10.10 per hour and the hospitality sector is much more attractive than it used to be, having seen wages rise substantially.
Exploitation in the social care sector is endemic
The adult minimum wage is £9.50 per hour, yet the average rate of pay for care workers is £9.01. In some cases, residential care workers are, illegally, paid less than the minimum wage but often the low rate of pay is due to lower rates for overnight ‘sleep in’ duty, hours that extend beyond the shift contracted, charges for uniforms and other ‘expenses’.
Between 2011 and 2018 HMRC found 119 care homes paying below the minimum wage. In ‘naming and shaming’ six providers (the worst and most persistent offenders) HMRC noted that 34,000 workers were paid below the minimum wage and £2.1mn was therefore owed in lost wages from these six companies alone.
Many staff are employed on zero-hours contracts with fragmented hours which reduce the value of their wage further. Some 68% of social care employees have either A-level or NVQ level three qualifications, so this is not unskilled work. Four out of five social care employees are women and the workforce is older than the national average. Part time working is prevalent and the percentage of care workers born outside the UK (based on 2019 figures) is 23%.
Care work is physically and emotionally draining. During the early months of the covid pandemic social care staff died disproportionately in comparison with the wider population. They were under-protected through lack of or poor PPE and the discharging of sick people into care homes. The government also neglected the sector and put lives at risk.
The government’s approach to recruitment has been to place, from April 2022, care workers on the shortage occupation list and require a minimum wage for immigrant employees of £10.10.
Steve Barclay also announced a massive nursing recruitment drive from India, Sri Lanka and the Philippines. He said his focus was to relieve the pressures on hospitals caused by insufficient staff in the care sector. One strategy was for social care to recruit nurses with good nursing qualifications but whose standard of English was not sufficient to enable them to work as nurses in the NHS.
Unless a care homeowner or manager is prepared to disadvantage their existing staff or increase pay levels overall, they are unlikely to recruit from abroad on these terms. Or, as is more likely (and as the HMRC findings suggest) they may seek to find ways of clawing back part of those wages, especially from foreign workers. And although this is illegal, victims are unlikely to report it.
The government’s chosen approach exploits foreign workers in general. They can be sacked and deported at will should they upset their employer, whilst possibly still owing considerable amounts they have had to sign up for in recruitment fees. The government also charges high, up-front fees for visas (£479 per person for three years) and a health care supplement of £649 per person.
Government-supported recruitment drives already use agencies where exploitation and debt bondage in the country of origin is common and agency or employer repayment clauses (the UK equivalent of debt bondage) which are used in health and social care are common in the UK. These tie an employee to a named employer for up to five years or face a penalty of up to £14,000 and deportation. This risks exploited employees suffering in silence or disappearing into the grey economy to survive as illegal immigrants.
Additionally, UK employers have been very cavalier about the conditions immigrant employees are recruited under and are content to offload the responsibility to agencies, accepting their paper assurances that all is being done legally. In July, the Financial Times reported one example of six care workers in Wales some of whom who had been employed under debt bondage while others had arrived in the UK on a student visa. It was their colleagues, not the homeowner or managers, who raised the alarm.
Marketisation of care increases risks of exploitation
Workers in private residential care are much more at risk of exploitation than those employed in the publicly accountable NHS. According to IPPR research undertaken in 2019, 84% of adult residential care beds are privately owned. Big providers, often funded through private equity firms and loaded with debt to increase profits, dominate the sector. Their complicated financial structures and tax avoidance leave them vulnerable to bankruptcy, and some big providers such as Four Seasons have gone into administration in recent years. Economies of scale and reducing staff costs are the only way to make these homes profitable.
Social care funding is complicated and research shows that many people do not understand it, or understand it poorly. Much of the public debate focusses on the impact funding has on private wealth or property rather than the nature of care people would like to see and how, overall, it should be funded. Stories of older people or people with disabilities being neglected in care homes raise concerns about how one’s loved ones will be cared for when the need arises but, overall, the public is not very engaged with its organisation and funding. When people understand current financing and the needs of those being cared for, most are inclined to think it should be funded in a way that is similar to the NHS.
Public attitudes towards immigration
An Ipsos/MORI (2021) survey of social attitudes towards immigration indicate that since 2016 and the consequent ‘Brexit’ from the EU, people’s attitudes have “softened” with 46% viewing the contribution of immigrants as positive and only 26% viewing it negatively – a reversal of the situation in 2015. The survey found “that 46% of the public would support a temporary relaxation in immigration restrictions to help British businesses if they need an additional supply of skills and labour to assist with economic recovery”.
At the same time, however, the HSCC report noted the high level of racism health and social care workers experience in the work place from managers, colleagues and patients. These ranged from unjustified failure to progress, disciplinary reports and poor career opportunities to outright hostility and assaults.
So, it seems that while people may now better understand that immigrant workers are needed, that they saved the NHS from collapse and bore much of the brunt of covid’s devastation, this has not effectively translated into better behaviour towards them.
The government and public are colluding in exploitation
The Ipsos/ MORI research coupled with the HSCC report suggests that the British public and the government is content to see higher immigration but only if it is for the purpose of relieving the difficulties UK citizens face.
Continued government anti-immigrant rhetoric and dismissal of the contribution immigrants make to the UK has encouraged public hostility. Many government policies actively support an environment in which exploitative working conditions thrive and it has failed to develop a properly staffed social care sector. A sector that exploits its staff cannot be trusted to protect the needs of the most vulnerable in its care.