Finding good work in a crisis

Nobody doubts that there is a crisis in adult social care.

It’s an international problem affecting most developed economies.

Put simply, governments can’t agree how to fund and provide care for ageing populations. And vast numbers of vulnerable adults are suffering as a result.

The study of the crisis, as it deepens and becomes more urgent, has been part of Carol Atkinson’s professional life for more than a decade.

The University’s Professor of Human Resources Management has – with her colleagues in the Centre for Decent Work and Productivity – been gathering and analysing data in the UK.

But it’s far from an isolated problem.

“This is very much an international challenge in neoliberal economies. The issues we find in the UK are almost entirely the same in countries such as Canada, Australia, Japan and America. To a slightly lesser extent, there are similar issues across most developed economies where you have an ageing population and you are looking at how care is delivered.”

Although it doesn’t account for all the problems being faced, many difficulties track back to inadequate funding.

In the UK, years of austerity in local government finances have squeezed budgets for social care. As a result, it has become more and more difficult for individuals to get state-funded support.

Carol said: “I know from my own research that the thresholds to get care have increased, and increased, and increased. You have to be really vulnerable now to qualify.

“There’s a whole tranche of people who aren’t sufficiently vulnerable who do need support and we, as a society, are leaving family and friends to step in. Where they can’t do that, people are struggling on alone.

“It doesn’t reflect well on us, as a society, that we are prepared to leave people in that position.”

As people are living longer they are developing more complex health conditions that make them more vulnerable and frail, so the demands on the system are ever increasing.

The funding problems in the sector don’t just restrict the supply of care. They are also damaging the quality of care.

The cost of caring

The UK Homecare Association calculates the cost per hour of delivering care is £18. But it’s commissioned at an average of £14 per hour.

This means some service providers have been cancelling contracts they can no longer afford to run, handing caring responsibilities back to the local authorities. It’s become frequent enough that most councils now have protocols to manage the handback of contracts.

The way other providers don’t lose £4 an hour is to cut corners on back office functions, training and paid travel time. 

The quality of care suffers, and providers struggle to keep hold of staff. Every year around a third of care workers leave their job – and a third of those leavers quit the care sector altogether.

It’s not a sustainable position, for the businesses in the sector or their stressed and demoralised staff.

During her research, Carol has spoken with hundreds of social care professionals, many of whom have heart-rending stories to tell.

“One commissioner expressed his concern that people would die ‘lonely and immoral deaths’ if something didn’t change,” she said.

“A care worker told us about having to put somebody on a commode and feed them at the same time because they only had 15 minutes to spend with that person.”

These aren’t isolated concerns or confessions.

Carol’s wider research focuses on employment quality - what makes good employment and the difference it can make to both the employer (through increased productivity and better service quality) and employees (through increased jobs satisfaction and professional development).

Reversing the decline

In 2007, she was approached by the industry body Skills for Care to do a study on precarious and vulnerable employment in adult social care.

She analysed the links between terms and conditions for care workers and the sector’s struggle to attract and keep its workforce. The work formed the basis of Skills for Care’s 2011 national recruitment and retention strategy.

And it led to a project for the Welsh Government in 2016 focusing on terms and conditions for providers of domiciliary care.

“People said generally if you don’t treat care workers well how can they provide good care, but there had been no in-depth analysis of that. We showed that problems with terms and conditions led to problems with recruitment and retention, and that was problematic for quality of care.

“It reduced continuity of care, which is important for an intimate service - you would want and prefer the same people to be looking after you. We also showed that it meant care wasn’t very reliable. People could turn up late or not at all if they were on zero hours contracts or appointments were poorly scheduled.

“And it wasn’t very flexible. You didn’t get the opportunity to train people and develop the skills needed to be flexible about the care they give. We showed that this compromised care quality.”

The evidence was used in consultations by the Welsh Government, which led to a change in the law - directly affecting the employment conditions of 19,500 workers and the care provided to over 23,000 people. After being in a job 13 weeks, care workers earned the right to request guaranteed hours contracts. And appointments had to be scheduled so that travel time didn’t eat into caring time.

In a sector where problems have continued to mount, this was an important step towards halting, and beginning to reverse, the decline.

Proof of a link between good working conditions, improved productivity and better recruitment and retention attracted the attention of Greater Manchester Combined Authority.

It commissioned a study from Manchester Met, which found further evidence of the link. The findings were reflected in a technical report for the region’s Independent Prosperity Review – the basis of the local Industrial Strategy.

There was cause for optimism. Recognition of the many benefits of good work in social care was growing. Practical steps were being taken to make long needed changes.

Then came Covid

And then, in early 2020, the Covid pandemic hit the UK. 

While few sectors of the economy or groups of people have remained untouched by Covid, its devastating impact has been felt among the most sharply in adult social care.

In July 2020, the Health Foundation published its findings about the first wave of Covid in the UK. It found that:

• since March, there had been 30,500 more deaths among care home residents than would normally be expected
• a further 4,500 excess deaths were recorded of people receiving care in their own homes – making them proportionally harder hit than care home residents
• social care workers were one of the occupational groups at highest risk of dying from Covid-19

A day of reckoning looked to have come.

“The sector is in crisis and has been for many years. The crisis predates Covid and has been exacerbated by Covid, but the problems weren’t caused by the pandemic,” Carol said.

During the early months of Covid, there started to be discussions at policy level about what needs to change.

Carol said: “People like me have been saying for a long time that we need an integrated health and social care service. And suddenly, that started to be talked about seriously.”

At its simplest, this would mean putting social care on the same footing as the NHS – nationally run, sustainably funded and committed to high standards.

Sweeping away the patchwork of struggling, underfunded, locally commissioned services wouldn’t be cheap. Estimates have put the cost at close to £1.7billion for staff costs alone.

Carol said: “The systemic change required and the cost attached to it is huge. There’s no two ways about that.

“But so are the benefits. And you might find that there are some significant cost savings in the NHS.

“We’ve done some preliminary, unpublished work looking at whether you could reduce hospital admissions. A lot of admissions for older people are due to falls and dehydration. With proper social care they are very easily avoided.

“Another big cost is the delayed transfer of care, where we can’t get people out of hospital because we can’t get packages to support them in their own home. Properly funding and managing social care could reduce those kinds of costs.”

Part of the reason why the crisis in adult social care has never been properly tackled, Carol believes, is because the work has never been given the same respect as medicine, despite the significant impact it has on the lives of hundreds of thousands of people.

“Adult social care is neglected. It’s underfunded. It’s often unloved. And yet at times of crisis we see just how much we rely upon it and how important it is. We need political will to move from this situation to one that resolves the issues.”

The political will does appear to have been stirred by the pandemic.

“We won’t wait to fix the problem of social care that every government has flunked for the last 30 years,” the British Prime Minister Boris Johnson said in June 2020.

He promised to end the injustice of some people having to sell their homes to finance the costs of their care while others don’t.

And he pledged to build a cross-party consensus.

Although the government plans remained unpublished at the end of 2020, there may still be cause for hope – albeit not quickly.

“To an extent, I think something is going to have to change because we are in such a crisis,” Carol said.

“However, we have been in that state of crisis for some years now. I don’t think things will change quickly. I’m not confident that the funding mechanisms required will be delivered. I’d love to be wrong.”

What happens next may well depend on public support, or lack of it.

The outpouring of affection for the NHS and other keyworkers seen during Clap for Carers in the initial phase of the pandemic hasn’t yet translated into action.

“If you look at our keyworkers – the supermarket workers, bus drivers, dustbin people, social care workers – these unglamorous foundational jobs had a light shone on them in a very different way and they were recognised as the people who kept the country going. But in terms of employment quality there’s been very little change so far.”

Finding good work

Carol won’t be deterred. She and colleagues at the Centre for Decent Work and Productivity are starting what’s been called a ‘good employment learning lab’ on adult social care.

This innovative two-year project, funded by the Economic and Social Research Council, aims to find ways to improve management practices – around recruitment, skills building, team work and flexible working – that will have an impact on recruitment and retention as well as care quality as a measure of productivity. 

Just as the crisis in social care crosses national boundaries, there is international interest in the benefits of good work –and it’s been gathering pace in recent years.

The International Labour Organisation, which promotes employment rights in 187 countries, published decent work standards in 2003. The United Nations added decent work to its sustainable development goals in 2015.

In the UK, the government published Matthew Taylor’s review of modern working practices in 2017, which stressed the importance of good quality work. The representative body for human resource professionals, the CIPD publishes an annual good work index of job quality.

But what is good work?

“At a very basic level good work is about secure terms and conditions of employment, a decent wage – maybe a living wage – opportunities for training, and having a voice – being listened to,” Carol said.

“At a slightly more sophisticated level, it’s about workplace flexibility. And at a more sophisticated level again, it can also be about meaningful work.

“There has been recognition of the need for good work and the importance of good work.”

Pre-Covid it was quite common for care workers to report high levels of job satisfaction because what they do is important and meaningful.

They might have expressed dissatisfaction with the terms and conditions of employment, but satisfaction with it being meaningful work. They have autonomy, the work makes a noticeable difference to people’s lives, they connect with people and changes their lives.

“Care work has the potential to be really good work,” Carol said.

“A lot of care workers told us that having to deliver care that was not what they would consider high quality was more likely to make them leave the role than term and conditions themselves.

“You don’t join that profession to get rich, you do it to provide proper care.

“On the whole there’s a real will to deliver good care and where it fails it’s often because we’ve failed the workers themselves.

“What I hope is that our work continues to shine a light on the crisis in social care and the need for good work more generally.

“We’ll continue to press at policy level for change. It’s too important not to.”