Lifting the veil: removing the invisibility of adult social care

Invisibility and the challenges faced by the social care workforce

The Committee has requested views on the challenges in adult social care, including its ‘invisibility’.

The historic social organisation of care has seen women disproportionately expected to carry out unpaid care work to support their families and communities. In the UK, 58% of the 6.5 million unpaid carers are women.1  Yet persistent gendered beliefs and expectations about women’s roles in household and societies means that care work typically remains under-recognised, undervalued and underpaid.

As more women have entered the workforce, they have been forced to juggle paid work with unpaid care, with the number of people providing unpaid care rising from 9.1 million to 13.6 million during the Covid-19 crisis.2 Many of those providing long-term unpaid care found that their caring responsibilities grew during the pandemic, with 38 per cent citing reduced availability of social care services as the reason for this increase. As a result, many reduce their time in paid work or leave the workplace altogether to have time to care. Social care services are an important means of improving unpaid carers’ quality of life – recent trade union research reveals social care services such as respite care support carers’ ability to cope with the demands placed on them by service users’ needs.3

The paid care sector has grown in recent decades to become one of the most important sectors in our economic infrastructure, contributing at least £50.3 billion to the economy and representing 6 per cent of total UK employment.4 Yet recent estimates suggest there are 1.5 million older adults with unmet care needs.5 An acute workforce crisis is at the heart of this challenge.

Evidence on employment conditions demonstrates the persistent under-recognition, undervaluation and underpayment of care work when it is carried out in the labour market – by a workforce in which women, Black and minority ethnic (BME) and migrant workers are overrepresented. TUC analysis shows 6 out of 10 care workers earn less than £10 per hour.6 24 per cent of the sector are employed on zero-hours contracts.7 This increases to 42 per cent when just accounting for the domiciliary care workforce. Neither are care workers fairly renumerated for their skills and experience. Since March 2016, the pay gap for experienced care staff compared to new starters has fallen from around 30 pence per hour to 6 pence per hour as of March 2021.8 In addition to low pay, work in the care sector is characterised by high levels of job insecurity, widespread abuse of employment rights and limited development opportunities.

This has led to a serious recruitment and retention problem. Skills for Care analysis of 2021/21 data shows that there are 105,000 vacancies in adult social care, whilst turnover of staff is 34.4 per cent.9

A recent report from The Work Foundation and Total Jobs shows that of the top reasons for workers leaving the sector, 51 per cent cited wanting higher pay.10

The cumulative cost of losing experienced, skilled and compassionate staff for employers and those receiving care is immeasurable. High turnover undermines the quality of care people receive, with inconsistent staffing limiting providers’ ability to deliver person-centred care. The underfunding of care that results in wage suppression also leads to the commissioning of care services focused on a production line of task-to-time slots rather than what the cared for person needs – resulting in high levels of unmet need and poor-quality care.

Without urgent action, the crisis in social care is set to grow. A surge in care needs stemming from the pandemic and an ageing population mean the sector will need to recruit an estimated 480,000 extra jobs nationally (an increase of 29 per cent of the current number of social care jobs) by 2035 to keep up with the ageing population.11

The role of the government in the social care workforce crisis

The public is overwhelmingly in favour of reforming social care and improving pay and conditions for workers. Responses to polling by TUC and Britain Thinks in 202112 showed that 95% of respondents agreed that care workers do a valuable job in UK society; 9 in 10 workers (88%) felt that more should be done to ensure social care staff have job security and improved working conditions; and 86% believe that improving working conditions would improve the quality of care. Analysis of NatCen's 2021 British Social Attitudes survey by Nuffield Trust and The King's Fund showed that decent work for health and care workers is a key concern – 50 per cent of respondents said they were dissatisfied with social care, with poor pay, working conditions and training for social care staff given as the main reasons.13

Successive Governments have directly contributed to the social care workforce crisis – whether by design or inaction. When the current Prime Minister, newly elected, first stood on the steps of 10 Downing Street in 2019, he made fixing social care the test of his premiership.14  Yet his Government has failed to respond meaningfully to public support for quality employment in the social care system.

Key challenges include:

Lack of investment

Social care faces a perfect storm in which the impact of years of chronic underfunding has been exacerbated by increasing demand and the knock-on impact of cuts to other key public services. Social care has a low profile among the public services, particularly when compared to the NHS – despite the frequent interaction between the two parts of the health and care system. Cuts to local authority budgets – the main source of funding for social care – since 2010 have severely restricted local authority expenditure. TUC analysis revealed between 2010/2011 and 2018/19, social care spending fell by nearly £600m in England, representing an average reduction of £37 per head, despite the increases in demand from an ageing population with increasingly complex care needs.15  This has produced a situation in which the needs of many of society’s most vulnerable people are not being met and where care workers are too often exposed to exploitation.

Outsourcing

Our social care system is based on a fragmented, competition-driven provider market - influenced by the bottom line rather than community need, encouraging short-term commissioning and leading to poorer care outcomes for those in receipt of care. Just 7 per cent of adult social care staff are employed directly by local authorities, with 7 per cent in the NHS, with remaining 1.3 million working for private providers and individuals.16

The care home sector supports around 410,000 residents across 11,300 homes from 5500 different providers, while in home care almost 900,000 people receive help from over 10,000 regulated providers.17 While many providers are small companies a few major providers dominate a significant share of the market, propped up by high levels of borrowing, complicated corporate structures and cost-cutting measures such as tax avoidance and low staff pay.18  Inadequate government investment means that the cost of providing quality care services often outstrips the funding available, contributing to downward pressure on workers’ pay and conditions. Recent TUC analysis showed that it takes care workers in the private sector an average of 12 weeks to earn what the average highest paid directors at some of the biggest providers earns in just one day.19

Persistently poor outcomes mean this system is failing service users, staff and the public who fund it – demonstrating the compelling case for reducing the role of the private companies and delivering these services through the public sector.

Lack of a social care workforce strategy

There have been no shortage of green papers, white papers, commissions, and other proposals over the past 20 years, all promising to provide an answer to the social care conundrum. There has been no national workforce strategy for social care since the publication of Working to Put People First in 2009.20 The 2021 People at the Heart of Care: adult social care reform white paper21 contains some positive initiatives that seek to address the problems in the sector: for example, the focus on career progression, the tentative moves towards registration of care workers, and proposed changes to the care certificate. Overall, though, the white paper offers neither the ambition nor the funding necessary to seriously challenge the status quo. Critically, pay was virtually absent. There is no way of solving the workforce crisis in social care without addressing poverty wages; care workers need an urgent pay rise now.

Poor integration with other public services

In recent years there has been a short-sighted inability to understand the interconnectedness of our public services: over the past decade the government offered the NHS greater protection from austerity than most services, but social care has been allowed to hit rock bottom. This ignores the impact that underinvestment in one sector has on the other, with issues such as delayed transfers of care becoming a problem that increasingly occupies NHS leaders.

Botched integration initiatives have not helped either. The current government is awash with ideas for how to bring about integration. But there seems to be no coherent strategy for turning laudable-sounding plans into actual progress on the ground. On the surface, much of what is in the most recent integration white paper is laudable.22  But, as with much of the rest of the government’s policy agenda for health and social care, such plans are doomed to fail without sufficient staff or investment to deliver them.

It also remains unclear how new plans will interact with the system currently being legislated to bring in Integrated Care Systems (ICSs) across England via the newly established Health & Care Act 2022. In fact, the suggestion of a single accountable leader responsible for local integration (as included in the white paper) seems directly at odds with the Health & Care Act that has legislated for the split accountabilities of the NHS (centrally to NHS England) and councils (locally to their populations). Moreover, it would make sense for one set of reforms to be allowed to bed in before trying to superimpose another set on top.

Either way, any attempts at fostering genuine integration will continue to fail unless greater emphasis is placed on achieving parity between the sectors. The lack of vastly improved funding for social care, the continued failure to provide an urgent pay uplift for care workers and the paucity of ambition of the 2021 adult social care white paper in terms of major system reform is deeply damaging for the care sector, but it also places a serious question mark against the government’s claims that ICSs will be able to bring about greater integration between health and social care.

The effects of the Covid-19 pandemic and associated policy measures

The Committee has requested evidence of the effect of the Covid-19 pandemic on adult social care.

The pandemic has been the ultimate stress test for adult social care. The structural problems in the system that trade unions have been concerned about for decades were hugely exacerbated following the onset of the crisis. The Covid-19 pandemic has been a traumatic period for the social care sector. Between 2 March and 12 June 2020, 28,186 “excess deaths” were recorded in care homes, with 18,500 deaths confirmed as coronavirus related.23  In 2020 Covid-19 the mortality rate for care workers was significantly higher than the covid mortality rate across the working age population.24

Surveys by trade unions among their members working in social care throughout the pandemic starkly demonstrate the acute challenges faced by this workforce. A June 2020 survey of social care workers25  working throughout the pandemic in England identified deep concerns about safety - almost 40 per cent of respondents said that they did not feel safe at work, with lack of personal protective equipment (PPE), safe procedures and lack of access to testing emerging as key themes. Concerningly, 37 per cent reported not bring paid during self-isolation or while off sick meaning they faced a stark choice of going to work and risking contaminating service users or staying at home with no money to live on. As one worker explained:

“My employer (higher up, not at office level) has done very little about the covid-19 threat, using our building as a meeting point for people from across the region, refusing to let us wear PPE, sending at risk children to school despite government advice, and threatening staff who have spoken up with being redeployed elsewhere or making them fear for their jobs.”

A survey of more than 1,200 care workers carried out between December 2020 and January 2021 identified significant negative mental health impacts on care workers26 : 75 per cent said that their work during the Covid-19 pandemic has had a serious negative impact on their mental health. Women, disabled, residential, and care workers who were only entitled to statutory sick pay – paid at a rate of one-fifth of average weekly earnings27 - all reported lower mental health scores.

Negative impacts of the pandemic on care services and workers have continued – social care workers surveyed in late 2021 virtually all (97 per cent) reported that their employers were experiencing workforce shortages, with burnout, overwork and low pay cited as the main causes. Worryingly, nearly a third (31 per cent) reported that staffing levels were dangerously low and affecting the quality of care provided, corresponding with the aforementioned high number of vacancIes in the sector.

Poor policy decisions have strongly contributed to this situation.

The dependency on agency staff and zero-hours contracts – driving low pay and poor terms and conditions across the sector – and the difficulty of getting a handle on testing in a broken, fragmented system, meant the virus spread rapidly through residential homes and to vulnerable people in their own homes. The government’s “NHS first” approach and its policy of discharging NHS patients into care homes to free up hospital beds - without a testing regime and adequate PPE – accelerated this, putting care service users and workers at substantial risk.28

The fragmentation of social care compounded these challenges. Cash-strapped local authorities were left to meet increased service demand without adequate funds, capacity or timely information and a disparate provider landscape contributed to slow and uncoordinated PPE distribution as well as the inability to comprehensively test care workers.29  The gaps in the response highlight the huge shortcomings in the government's current approach to organising adult social care. While staff testing and the distribution of PPE was far from perfect in the NHS, there were at least clear mechanisms to implement measures in hospitals and other healthcare settings – a key reason to move towards delivering social care through the public sector.30

In November 2021 adult social care workers became the first group of workers to be subject to mandatory Covid-19 vaccination, despite opposition from trade unions who highlighted of the financial and operational costs of procuring and administering vaccines as well as equalities and legal implications given the mandate disproportionately affected those with protected characteristics, including Black and minority ethnic (BME) workers, women of child-bearing age, and young people, among other challenges.31 The warnings given by trade unions that mandatory vaccinations in social care would exacerbate the already acute recruitment and retention problem were quickly borne out.

Threats to adult social care workers – and those in receipt of care – have continued, with the recent government decision to end the Covid infection control fund (ICF). While the ICF has not always functioned optimally, the lack of this extra (albeit short-term) funding means that many staff will potentially find they are not able to receive sick pay if they get Covid. As unions and providers have pointed out, this is an “incredibly dangerous move that will cost lives.”32

Fixing the system: A New Deal for social care

The Committee has requested proposals on the key changes needed to reduce the invisibility of adult social care, and how care and support arrangements can best be designed.

The trade union vision for social care is clear. We want every person to be able to access the high-quality care services they need in every part of the country, no matter what their circumstance or “needs threshold.” We want all care workers to receive good pay, terms and conditions, have security and dignity at work, and a recognition of their skills and pathways to progress their career. We want a social care system that supports everyone. This can be achieved through a collective approach to managing risk, with collective provision and progressive taxation – a universal service.

This requires a workforce strategy which sits alongside trade union asks for greater and longer-term funding for the sector, reform of the fragmented private provider market towards insourcing of care services, and ensuring accountability and service user need is built into the system.

As we set out in our recent ‘A new deal for Social Care: A new deal for the workforce’ report, our recommendations to achieve this are:

1. Ensure fair pay and conditions for social care workers by setting minimum standards of employment including a new sectoral minimum wage of at least £10 per hour
2. Implement a new investment strategy that a) provides immediate funding to fill all 105,000 social care vacancies, and b) establishes future rises at a level that allows local authorities to meet rising demand
3. Enable the co-creation of high-quality working conditions in the social care sector by establishing a new Social Care Forum to coordinate the delivery and development of services, and the negotiation of a new workforce strategy
4. Reduce the role of private sector providers and move towards insourcing of care services

1. Ensure fair pay and conditions for social care workers by setting minimum standards of employment including a new sectoral minimum wage of at least £10 per hour

We can transform the way we deliver care in this country by transforming the pay and conditions of the workforce. That starts with pulling care workers out of poverty and guaranteeing a new sectoral minimum wage of at least £10 per hour. Raising pay would help tackle the single biggest challenge in care - recruiting and retaining staff.

Recent analysis by Landsman Economics for the TUC shows the cost of doing so is affordable. The gross cost to the Treasury of a new minimum wage is £434 million, with a net cost of £227 million because of increased tax revenue and reduced benefit spend. As a result, 580,000 social care staff would see their pay rise immediately. The majority of those are women, with almost half a million women (492,000) standing to gain from such a rise. Black and ethnic minority (BME) workers would benefit too, with 129,000 seeing their pay rise.

Workers overrepresented in the lowest paid areas of care would stand to gain the most, with 492,000 women working in social care benefitting and 129,000 Black and ethnic minority (BME) workers benefitting. These are the same care workers that have been on the frontline of caring for our communities during the pandemic, risking their lives to care for our loved ones. It is only right that we show our appreciation through decent pay and working conditions rather than through applause or badges.

2. Implement a new investment strategy that a) provides immediate funding to fill all 105,000 social care vacancies, and b) establishes future rises at a level that allows local authorities to meet rising demand

To meet the true cost of delivering decent social care we should ask everyone in our society to make a fair contribution to a service which benefits us all. This means the wealthy should play a central role in fixing our social care system.

At the moment the money you make from working is taxed at a higher rate than the money you make from selling shares or a second home. The average care-home worker can pay a bigger share of her income in tax to fund the social care system than the private equity magnate who profits from buying up care homes to re-sell them. That’s helped the rich get richer in recent years – with the wealth gap between the average family and the top ten per cent rising by an extra £44,000 in the pandemic alone.33

Part of the funding for a new social care system should come from taxing wealth on the same basis we tax income. IPPR has estimated that equalising Capital Gains Tax rates with income tax rates and removing exemptions could raise, on average, up to £17bn a year.34 This would be a fairer way to raise revenue than the recent National Insurance increase which has a disproportionate impact on young and low paid workers, but no impact on those earning money from property or shares.

In the short term, this increased fiscal space should be used to transform the pay of care workers through the new sectoral minimum wage of at least £10 per hour. The long-term aim for investment should be for adult social care to meet rising need as a universal service, free at the point of use, and paid for from general taxation. This would remove arbitrary and unfair eligibility thresholds, relieve unpaid carers of their invisible labour, deliver higher quality care, deliver sustainable funding and ensure true accountability and transparency to the public.

3. Enable the co-creation of high-quality working conditions in the social care sector by establishing a new Social Care Forum to coordinate the delivery and development of services, and the negotiation of a new workforce strategy

One key element which could be implemented relatively quickly and at minimal cost, is the establishment of a national care body, made up of government, trade unions, employers and commissioners, to be established. This would mirror the NHS Social Partnership forum, and likewise would be able to develop and negotiate a workforce strategy for social care.

Such a body would be able to work with government on their long-awaited plans for social care, ensuring that it is fit for purpose to deliver quality employment and care. For the social care workforce, this should include setting minimum standards of employment, including:

• Pay and pensions – beyond £10 per hour, agreeing pay structures that pay staff properly for all hours worked, including overnight sleep-ins and travelling time between appointments and clients. There should also be transparent pay and grading structures, that allow for progression and reward fairly staff according to skills, experience and qualifications. There should be access to pension schemes and other terms and conditions, on parity with the NHS.
• Working time and holidays – including a right to minimum guaranteed hours to tackle the problems of zero hours contracts and other insecure employment. Holiday allowance and pay
• Equality issues – including maternity and paternity pay and leave, carers leave and a right to flexible working
• Health and safety – including agreed standards on health and safety, appropriate training workforce engagement through trade union committees, agreed standards for safe staffing levels and sick pay.
• Grievance and disciplinary process – including the right to trade union representation.
• Training and development – including registration of social care workers (with costs met by employers), skills recognition linked to pay and progression, agreed standards for training to ensure consistency and a right to paid time off to attend training.
• Work organisation, including the introduction of new technologies and ways of work – including involvement of staff in organising rotas and teams and a requirement to consult with staff over changes to workforce.

4. Reduce the role of private sector providers and move towards insourcing of care services

Fragmentation and competition among private care services providers has led to a race to the bottom in employment standards. The pandemic has shown that social care providers are unable to keep service users and staff safe and well-treated. There is a stronger case than ever to reform the for-profit model of care and stop public money leaking out into private profit, instead delivering these services through the public sector.

Research that shows that bringing services in-house means better quality services, reduced risk, lower costs, greater public support and accountability, more flexible services and better jobs, terms and conditions.35

Such a system would provide far greater reassurance and security to those receiving and delivering care. It would also enable care providers to have greater certainty over their funding streams and therefore to plan better for rising future need, including by putting in place the measures needed to provide the care workforce with quality employment.

Contact: Abigail Hunt, Policy Officer – public services.

Ahunt@tuc.org.uk

• 1 Public Services International (2020) Health and Social Care Workers and the Crisis of Neoliberalism
• 2 Carers UK. (2020) Carers Week 2020 Research Report. 
• 3 GMB Scotland (2022) Show you care: Voices from the frontline of Scotland’s broken social care sector
• 4 kills for Care (2021) The state of the adult social care sector and workforce in England (skillsforcare.org.uk) 
• 5 Age UK on unmet care needs https://www.ageuk.org.uk/latest-press/articles/2019/november/the-number-of- older-people-with-some-unmet-need-for-care-now-stands-at-1.5-million/
• 6 TUC analysis of Q4 2021 of the Labour Force Survey found that 58% of 'care workers and home carers' earn less than £10 per hour"
• 7 Skills for Care (2021) The state of the adult social care sector and workforce in England (skillsforcare.org.uk)
• 8 Ibid
• 9 Ibid
• 10 Totaljobs and The Work Foundation (2021) Social Care: A Guide To Attracting and Retaining a Thriving Workforce
• 11 Skills for Care (2021) The state of the adult social care sector and workforce in England (skillsforcare.org.uk)
• 12 Unpublished polling conducted by BritainThinks for TUC. 2,203 workers in England and Wales between 12 and 21 July 2021.
• 13 Wellings D, Jefferies D, Maguire D, Appleby J, Hemmings N, Morris J and Schlepper L (2022) Public satisfaction with the NHS and social care in 2021: Results from the British Social Attitudes survey. Report, King's Fund and Nuffield Trust. https://www.nuffieldtrust.org.uk/research/public-satisfaction-with-the-nhs-and-social-care-in-2021-results-from-the-british-social-attitudes-survey#acknowledgements
• 14 Homecare.co.uk (2019) Prime Minister Boris Johnson says he has a plan to 'fix the crisis in social care once and for all'
• 15 TUC (2020) Fixing Social Care: Better quality services and jobs
• 16 Community Integrated Care report ‘Unfair to Care’ https://www.unfairtocare.co.uk/
• 17 UNITE INSOURCING BRIEF
• 18 2019, IPPR research in UNITE insourcing brief
• 19 TUC analysis of director pay at care providers https://www.mirror.co.uk/news/politics/struggling-frontline- carers-308-week-24839008 
• 20 Department of Health, Working to Put People First: The Strategy for the Adult Social Care Workforce in England, April 2009
• 21 Department of Health and Social Care (2022) People at the Heart of Care: adult social care reform
• 22 Department of Health and Social Care (2022) Health and social care integration: joining up care for people, places and populations
• 23 ONS (2021) Deaths involving COVID-19 in the care sector, England and Wales - Office for National Statistics (ons.gov.uk)
• 24 Between March 2020 to December 2020, the age-standardised covid mortality rate for male care workers aged 20-64 was 109.9 per 100,000 people, and for women it was 47.1. This compares to 31.4 for all men aged 20-64, and 16.8 for all women aged 20-64. This means male care workers were 3.5 times more likely to die from covid, and female care workers were 2.8 times more likely. ONS (2021) Coronavirus (COVID-19) related deaths by occupation, England and Wales  
• 25 Unite the Union (2020) Time to insource social care services
• 26 GMB (2021) Three quarters of care workers’ mental health has worsened during pandemic
• 27 TUC (2020) Sick pay and debt | TUC
• 28 TUC (2021) A new deal for Social Care: A new deal for the workforce
• 29 Unite the Union (2020) Time to insource social care services
• 30 UNISON (2020) Care after Covid: A UNISON vision for social care
• 31 TUC (2021) A safe return to the workplace
• 32 The Guardian, Care homes in England demand revival of Covid fund to pay isolating staff, May 2022
• 33 TUC (2021) A new deal for Social Care: A new deal for the workforce
• 34 Shreya Nanda (2019) Reforming the taxation of income from wealth: revenue estimates for Labour, the Conservatives and the Liberal Democrats IPPR
• 35 Unite the Union (2020) Time to insource social care services