Recruitment, training and retention in health and social care: Dimensions speaks with the government’s Health Select Committee

Watch Dimensions MD Rachael Dodgson giving evidence to the Health Select Committee on 1 March 2022 from 10am, on Parliament TV.

Dimensions is by some measures the country’s largest not-for-profit support provider for people with learning disabilities and autism. Our 6000 colleagues work with over half the country’s local authorities, supporting people to live fulfilling lives in their local communities.

We are one of very few organisations to be independently recognised as a great place to work by the ‘Great Places to Work’ institute. Our colleague turnover rates are around half the sector average. We put a huge amount of energy into recruiting and retaining the right colleagues. And yet we, too, are now working through unprecedented workforce challenges.

A glance at our published accounts will show surplus around 1% in 2021 (we reinvest any surplus into achieving better lives for more people.) There is no excess profitability in our field of social care.

That is the context framing our response to the questions asked by the Health Select Committee Inquiry into recruitment, training and retention in health and social care:

 

What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

This is not about ‘bums on seats.’ A motivated, values-driven and skilled workforce will enable the people we support to gain choice and control in their lives, building independence and in many cases ultimately reducing the quantum of paid support required. This is the cornerstone of personalisation.

Whether or not government wishes to hear it, this issue is dominated both in the short and long term, by pay.

Pay is principally about money, a point we make repeatedly below. But it is also a strong signal of the value that society attributes to a job. We think social care is often considered inferior to the NHS because like for like, care workers are paid an inferior wage. And if care work is paid below jobs in retail it is, ergo, seen as inferior. The country gave NHS staff priority shopping slots, discounted taxi rides and so on. We did not do this for social care staff. We shifted Covid patients out of hospitals and into ill-equipped care homes. We “clapped for carers” but really and truly we clapped for the NHS.  Until care workers stop feeling inferior to their NHS peers, recruitment and retention in the sector will remain difficult. Pay – in terms of money and a sense of parity with the NHS – underpins it all.

The short answer here is for government to fund local authorities in a manner that enables them to commission adult social care at rates of pay that

• Ensure pay is never again a reason to prefer working in (say) retail or hospitality over care, and
• Ensure that registered manager jobs bearing significant levels of personal responsibility are paid at levels that attract outstanding leaders into the care sector

Below, we cite the steps we believe must happen to achieve the above.

1. Care and support must be accepted across Government as requiring workers with a specific set of skills that can be trained and / or assessed. Some of those skills include communication strategies and techniques, first aid, delegated nursing, medical knowledge and understanding of the management of complex conditions, problem solving, teamwork, attention to detail, empathy, reliability and emotional intelligence.
2. Having established their status as skilled roles, care and support roles should be benchmarked against NHS positions – we believe a care worker would sit at NHS Band 3.
3. Government must also benchmark typical alternative roles in other sectors to provide vital context around labour market supply and demand.
4. Government should introduce a national qualifications programme for support work, in line with the White Paper.
5. Central government must provide ringfenced funding to local authority adult social care at a level that enables their social care providers to set competitive rates of pay in line with the qualifications and benchmarking above.

There is no doubt that the above will cost more – probably considerably more – than social care today. But over time, it is reasonable to assume savings as

• Colleague retention improves – reducing agency and recruitment costs
• People receive better support, achieving higher levels of independence and thus reducing the amount of support they require

Finally, the Migration Advisory Committee should set the minimum pay for a foreign support worker to be employable via the Shortage Occupations List at the level of National Minimum Wage, not £20,480 as now.

What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

Whilst care is commissioned by local government (via a mix of 3rd and private sector organisations) it is, ultimately, funded by central government. That divide is the root of much of the current market failure.

In that context it is tempting to consider moving Adult Social Care responsibility from local government to the NHS (as part of ICS responsibilities.) However, we advise strongly against such a move; it has taken several decades to move social care away from a medical model and everything we know about the NHS suggests a return to a medical model would be swift and inevitable.

Instead, we would support a national support work skills framework, perhaps with qualifications and bandings administered by SkillsforCare, alongside ringfenced funding for local authority adult social care as described above and indeed as planned in the Social Care White Paper.

Care and support providers can then operate their own recruitment and retention programmes in line with their individual needs against this consistent backdrop.

Any national social care recruitment programme should aim to produce a ‘prospect pool’ that local support providers can tap into. In the context of this being a highly fragmented sector, we must not overestimate what a national, government-led recruitment campaign can achieve. For clarity, providing funding for recruitment campaigns alone cannot and will not solve the staffing crisis in social care.

Finally, it is a particular feature of the care sector that employees move between employers via Transfer of Undertaking Regulations (TUPE) transfers each time that a local authority decides to commission a new provider for a particular service. The resulting retraining requirement – as employees have to adjust to a new organisational culture, complete new mandatory training and understand new systems – is labour intensive. A consistent national training standard may reduce the retraining requirement following TUPE.

 

What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?

Brexit offers an important lesson:

Very few of our support workers were EU nationals. Consequently we anticipated that Brexit would have a minimal impact on our workforce.

What happened in reality, was that as Brexit impacted other sectors such as retail, hospitality and transport, they were able to attract some of our non-EU staff away – in the main through higher rates of pay. Our voluntary staff turnover increased as an indirect result of Brexit. And therefore, all measures to ease migration will be beneficial to our sector.

Dimensions does not take a position on the ‘correct balance’ between domestic and international recruitment but we do assert strongly that we must be able to recruit the right people into support roles.  People with the right values and who can acquire the right skills. People who are well matched to the individual they will be supporting. That is the cornerstone of all our recruitment regardless of source.

To those who ask why more of the long term unemployed population is not working in care, we would say that in our experience, only a minority of those we interview with this background demonstrate the values and aptitude for support work. The root causes of this are for other parts of government to consider.

 

What can the Government do to make it easier for staff to be recruited from countries from which it is ethically acceptable to recruit, with trusted training programmes?

The apprenticeship pathway enables us to use our apprenticeship levy, offering a broad suite of qualification options.

However, funding restrictions dictate that only apprenticeship pathways can be undertaken and learners must meet specific criteria. Eligibility criteria relate to residency status, length of time in the UK and number of hours worked per week.

The rules restrict some colleagues from undertaking an apprenticeship either temporarily or permanently, halting their development opportunities unless they can access a costly diploma-only option.

The problem is that apprenticeship funding is unavailable to colleagues that have not yet lived in the UK for 3 years. We can lose good colleagues as a result.

The 3-year marker creates additional problem for colleagues that need to apply for Level 2 rather than Level 3 (as they perhaps don’t have consistent access to the increased responsibilities required.) We are often challenged on why someone with 3 years’ experience would be applying for a Level 2. It is, to some extent, a Catch-22 situation.

With retention such a pressing challenge for social care employers at the moment, any issues such as this which can contribute to increased voluntary staff turnover are unwelcome.

 

What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

We note that when launching the Social Care White Paper, the Minister referenced a meeting with care workers who told her they were not motivated by money.

If this is true, those workers are not representative of the sector.

Try bringing your family up on 9.50 per hour, knowing you could earn £10.50 working at a supermarket, starting tomorrow. Try telling your children they can’t have such-and-such because you’ve chosen to earn less than you could. Then try telling them that you can’t be home for them, again, because there’s a staffing crisis and the person you support simply cannot be left alone. In the past decade, a sales assistant has gone from earning 13pph less than a care worker to 21p more (source: Skills for Care.)

Few people are in a position to make such a choice.

We have entered a cycle of low pay and burnout where every additional colleague to leave the sector increases the hours worked by those left behind. The only way to tackle this is through pay. We note that ADASS, the Association of Directors of Adult Social Services, has proposed a dedicated National Living Wage for social care workers, set at the level of NHS Band 3 (£11.50) which includes clinical support workers, therapy assistants, pharmacy assistants, administrative workers and clerical staff.

Dimensions asks all leavers to tell us why they’ve left. Other than pay and hours, a commonly-cited reason relates to local leadership (line management.) In our view, decades of underinvestment into social care has resulted in managers having high spans of control and yet, because great leaders are a scarce and costly resource, too many of those managers lack the soft leadership skills to cope. We all know, as does CQC, that great leadership underpins high quality support. So when considering investment into the sector, we must consider local leadership as well as frontline roles.

Lastly, Dimensions has been a vocal critic of the requirement for all social care staff to be vaccinated against Covid-19. We believe people are being put at far greater risk through lack of support staff than through unvaccinated staff, given all the precautions in place. We have lost good colleagues to the vaccination legislation at the worst possible time. Following the U-turn, we have seen a surge in job applications and many colleagues at risk of having to leave us will now be able to stay. But the whole process has been hugely expensive, stressful for all concerned and disruptive to relationships within support teams and with many people we support and their families.

 

Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

Geographically the toughest areas for recruitment are London and rural locations, together with wealthier areas where the cost of living is higher.

There is a growing postcode lottery, where some Local Authorities are specifying and funding a wage level higher than neighbouring authorities. This contributes to a sense of unfairness (and recruitment & retention challenges) across the workforce and can lead to very different care experiences across boundaries.

The two critical roles include Support Worker and Registered Manager. As described above, underpaying registered manager roles is particularly catastrophic, as strong leadership is a prerequisite to the delivery of great support.

 

What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

We note the government rejected the HSC’s latest call for independent workforce planning across health and social care, and we believe this is a mistake. With formal planning, comes the potential for a grown-up conversation about resource allocation.

Ongoing professional development of managers and leaders is critical. Whilst Skills for Care offers useful resources, we would like to see similar emphasis being given to this in social care as in the NHS, with commitments in a social care people plan mirroring those in the NHS People Plan.

There is a critical lack of digital literacy across the social care workforce, often reflecting digital exclusion in people’s personal lives. Specific skills examples include updating digital support records on apps, logging vaccination statuses and updating rotas. Digital skills are core to the development of the social care workforce. The social care White Paper acknowledged this and we look forward to hearing more detail. We would welcome further initiatives to accelerate the work we are already doing in this area.

We rely on Workforce Development Funding (WDF) to support several initiatives, including developing managers from black, Asian and minority ethnic backgrounds, and providing management development to new operational managers. However, completing the ASC-WDS (Adult Social Care Workforce Data Set) in order to claim WDF is intricate and labour-intensive and can result in artificial ineligibility due to the timing of bulk uploads of data. We would welcome efforts to improve this system.

A previous answer references unhelpful funding restrictions around apprenticeships for recent migrants; this answer is relevant to this question but not repeated here.

 

What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

ICS’s have a particular interest in minimising the number of people requiring to be admitted to hospital, and for preventing subsequent bed blocking.

Both these things are more likely if the social care workforce has a high number of vacancies or insufficiently skilled teams and therefore it is in the interests of the ICS to:

• work with local authorities to drive up pay and skills across the footprint
• encourage central government to set national standards, in line with our previous answers.

With appropriate training, more nursing tasks can be delegated to the social care workforce, enabling more people to leave hospital, sooner. However, when starting work in new areas we have encountered situations where significant nursing tasks have been routinely delegated with only informal training, something that can put people at risk.

ICSs have an additional, vital responsibility: to take a strong position against the return to medical models of support across social care. We are concerned that additional Health influence over social care could unwind decades of progress in this area. Simply put, people lead more fulfilling lives when all those around them take an holistic view of their life, setting their disability in a societal context rather than seeing it as a purely medical issue. This philosophical position must be reflected across all aspects of organisational culture, values, recruitment and training.

 

Are DBS checks a factor?

Yes. We are competing with sectors that do not require employees to have DBS checks and which can therefore get people started sooner. A month’s delay due to DBS can lead to many people not starting in social care employment at all.

The national target for DBS turnaround is 80% in 14 days. Nationally performance has been declining through 2021 and this target is now not being met (88% May 2021, 78% Dec 21.)

Locally, there are significant variations between individual police force turnaround performance which impacts directly on recruitment in some areas.

Many individuals we try to recruit reach ‘stage 4’ which is a 60d+ turnaround time. Many of those will find other jobs.